Organization
JACOB S LAKE DDS LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACOB S LAKE DDS (OWNER)
(847) 229-1700
Entity
Organization
Contact information
Practice address
15 E DUNDEE RD, BUFFALO GROVE, IL 60089-4383
(847) 229-1700
(847) 229-1737
Mailing address
15 E. DUNDEE RD, BUFFALO GROVE, IL 60089
(847) 229-1700
(847) 229-1737
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019016208
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104857
—
IL
05
—
105621
—
IL
05
—
105622
—
IL
05
—
105875
—
IL
05
—
109096
—
IL
05
—
197950
—
IL
Enumeration date
06/12/2008
Last updated
12/30/2011
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