Provider Demographics
NPI:1053480988
Name:PETER W JACOBSEN DDS PLLC
Entity type:Organization
Organization Name:PETER W JACOBSEN DDS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CIELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-413-8525
Mailing Address - Street 1:27016 MAPLE VALLEY BLK DIAMOND RD SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038
Mailing Address - Country:US
Mailing Address - Phone:425-413-8525
Mailing Address - Fax:425-413-8599
Practice Address - Street 1:27016 MAPLE VALLEY BLK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038
Practice Address - Country:US
Practice Address - Phone:425-413-8525
Practice Address - Fax:425-413-8599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000052671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty