Provider Demographics
NPI:1871622118
Name:SCHLEE, JACOB (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:SCHLEE
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 1:15378 HARRIS SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62951-2807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSTON CITY
Practice Address - State:IL
Practice Address - Zip Code:62951-1602
Practice Address - Country:US
Practice Address - Phone:618-983-6961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice