MEDICARE: BLAIN JACOBSON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	56390	CA

General Provider Information

NPI Number	:	1700049749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAIN JACOBSON DMD

Provider Business Mailing Address
First Line	:	6910 DOUGLAS BLVD STE A
Second Line	:	#A
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-6276
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6910 DOUGLAS BLVD STE A
Second Line	:
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-6276
Country	:	US
Telephone Number	:	916-813-5363
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	12/18/2008

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