Provider Demographics
NPI:1407261852
Name:PHILIP, JACOB (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PHILIP
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 1:2050 E ALGONQUIN RD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4144
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:847-496-4850
Practice Address - Street 1:802 N 9TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:847-701-1457
Practice Address - Fax:847-496-7603
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190298401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice