Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | ME119107 | FL |
NPI | 1588823983 |
---|---|
Provider Name | Jacob Gregory Yetzer |
First Address | Rochester, MN 55905-0001 |
Second Address | Robbinsdale, MN 55422-2962 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2008 |
Last Update Date | 28/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003147783A | (05) | GA |
011938600 | (05) | FL |