Provider Demographics
NPI:1871712984
Name:WAYNE S JACOBSON DDS LTD
Entity type:Organization
Organization Name:WAYNE S JACOBSON DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-963-9280
Mailing Address - Street 1:1440 MAPLE AVE
Mailing Address - Street 2:3A
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-4134
Mailing Address - Country:US
Mailing Address - Phone:630-963-9280
Mailing Address - Fax:
Practice Address - Street 1:1440 MAPLE AVE
Practice Address - Street 2:3A
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-4134
Practice Address - Country:US
Practice Address - Phone:630-963-9280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190151311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty