Provider Demographics
NPI:1053414615
Name:THAYER, JACOB BRADY (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:BRADY
Last Name:THAYER
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 1:5426 MORNINGVIEW TER
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7573
Mailing Address - Country:US
Mailing Address - Phone:313-468-2162
Mailing Address - Fax:
Practice Address - Street 1:820 BYRON RD STE 800
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1072
Practice Address - Country:US
Practice Address - Phone:517-546-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010191451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice