Basic Information
| Provider Information | |||||||||
| NPI: | 1114161940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOMBURG | ||||||||
| FirstName: | HILLARY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 ALEX LN | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253042952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047342040 | ||||||||
| FaxNumber: | 3047342047 | ||||||||
| Practice Location | |||||||||
| Address1: | 6135 SISSONVILLE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253129444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049841576 | ||||||||
| FaxNumber: | 3049841565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 3970 | WV | N | Dental Providers | Dentist | 122300000X | IN PROCESS | OH | N | Dental Providers | Dentist | 122300000X | 3870 | WV | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 3810018626 | 05 | WV | MEDICAID |