Provider Demographics
NPI:1043479827
Name:JACOBSON, MARC (DDS)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10521 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5584
Mailing Address - Country:US
Mailing Address - Phone:262-241-2060
Mailing Address - Fax:262-241-2064
Practice Address - Street 1:10521 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5584
Practice Address - Country:US
Practice Address - Phone:262-241-2060
Practice Address - Fax:262-241-2064
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2475-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33412900Medicaid