Provider Demographics
NPI:1912283730
Name:HIGHLAND PARK OMS
Entity Type:Organization
Organization Name:HIGHLAND PARK OMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:847-433-6636
Mailing Address - Street 1:1893 SHERIDAN RD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035
Mailing Address - Country:US
Mailing Address - Phone:847-433-6636
Mailing Address - Fax:847-433-2090
Practice Address - Street 1:1893 SHERIDAN RD
Practice Address - Street 2:SUITE 311
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2628
Practice Address - Country:US
Practice Address - Phone:847-433-6636
Practice Address - Fax:847-433-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190229481223S0112X
IL0210020591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty