MEDICARE: DR. JACOB S LAKE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		IL

General Provider Information

NPI Number	:	1811979933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB S LAKE DDS

Provider Business Mailing Address
First Line	:	1800 MISSION HILLS RD
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-5750
Country	:	US
Telephone Number	:	847-562-0808
Fax Number	:

Provider Business Practice Location Address
First Line	:	2806 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-1502
Country	:	US
Telephone Number	:	773-973-1100
Fax Number	:	773-973-1531

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	07/08/2007

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