Provider Demographics
NPI:1588070148
Name:HPOMS
Entity type:Organization
Organization Name:HPOMS
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, PC
Authorized Official - Phone:847-433-6636
Mailing Address - Street 1:1893 SHERIDAN RD SUITE 311
Mailing Address - Street 2:
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 SUITE 311
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
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:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.022948261QD0000X
IL021.002059261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental