Provider Demographics
NPI:1992795710
Name:JACOB, GREGORY S (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:JACOB
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 1:9672 REDING CIR
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1551
Mailing Address - Country:US
Mailing Address - Phone:847-298-8954
Mailing Address - Fax:847-724-2113
Practice Address - Street 1:2400 RAVINE WAY
Practice Address - Street 2:STE 500
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7652
Practice Address - Country:US
Practice Address - Phone:847-509-1990
Practice Address - Fax:847-509-1992
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI593215122300000X
IL019019708122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist