Provider Demographics
NPI:1871277574
Name:LEE, JAKOB DOUGLAS (DDS)
Entity type:Individual
Prefix:
First Name:JAKOB
Middle Name:DOUGLAS
Last Name:LEE
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 1:898 44TH ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9508
Mailing Address - Country:US
Mailing Address - Phone:616-669-5595
Mailing Address - Fax:888-453-2029
Practice Address - Street 1:898 44TH ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-9508
Practice Address - Country:US
Practice Address - Phone:616-669-5595
Practice Address - Fax:888-453-2029
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016016511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice