Provider Demographics
NPI:1114161940
Name:HOMBURG, HILLARY J (DDS)
Entity Type:Individual
Prefix:
First Name:HILLARY
Middle Name:J
Last Name:HOMBURG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ALEX LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2952
Mailing Address - Country:US
Mailing Address - Phone:304-734-2040
Mailing Address - Fax:304-734-2047
Practice Address - Street 1:6135 SISSONVILLE DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-9444
Practice Address - Country:US
Practice Address - Phone:304-984-1576
Practice Address - Fax:304-984-1565
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3970122300000X
OHIN PROCESS122300000X
WV3870122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018626Medicaid