Healthcare Provider Details

I. General information

NPI: 1992795710
Provider Name (Legal Business Name): GREGORY S JACOB DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9672 REDING CIR
DES PLAINES IL
60016-1551
US

IV. Provider business mailing address

9672 REDING CIR
DES PLAINES IL
60016-1551
US

V. Phone/Fax

Practice location:
  • Phone: 630-347-0883
  • Fax:
Mailing address:
  • Phone: 630-347-0883
  • Fax: 847-724-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number593215
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019019708
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: