1568857464 NPI number — JACOBSON DENTAL CORP

Table of content: (NPI 1568857464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568857464 NPI number — JACOBSON DENTAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACOBSON DENTAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHILDREN'S CHOICE DENTAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568857464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3655 TORRANCE BLVD STE 425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90503-4844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-877-7450
Provider Business Mailing Address Fax Number:
844-534-8464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4074 FAIRMOUNT AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
691-996-9543
Provider Business Practice Location Address Fax Number:
844-534-8464
Provider Enumeration Date:
03/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSON
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
916-877-7450

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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