Basic Information
| Provider Information | |||||||||
| NPI: | 1083934046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | DINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PICKLE | ||||||||
| OtherFirstName: | DINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 905 SPRUCE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064616935 | ||||||||
| FaxNumber: | 2064618382 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 S MYRTLE ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981183529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064616981 | ||||||||
| FaxNumber: | 2064618581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2010 | ||||||||
| LastUpdateDate: | 06/01/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH00006726 | WA | Y | Dental Providers | Dental Hygienist | 124Q00000X | 2665 | KS | N | Dental Providers | Dental Hygienist |
No ID Information.