Provider Demographics
NPI:1871293688
Name:JACOBS DENTAL GROUP LLC
Entity type:Organization
Organization Name:JACOBS DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-382-6660
Mailing Address - Street 1:2916 W STOLLEY PARK ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-6807
Mailing Address - Country:US
Mailing Address - Phone:308-382-6660
Mailing Address - Fax:308-381-9809
Practice Address - Street 1:2916 W STOLLEY PARK ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-6807
Practice Address - Country:US
Practice Address - Phone:308-382-6660
Practice Address - Fax:308-381-9809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty