Healthcare Provider Details

I. General information

NPI: 1093807372
Provider Name (Legal Business Name): ROBERT NUDERA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 N MILWAUKEE AVE
CHICAGO IL
60622-4188
US

IV. Provider business mailing address

875 N MILWAUKEE AVE
CHICAGO IL
60622-4188
US

V. Phone/Fax

Practice location:
  • Phone: 312-455-9800
  • Fax: 312-455-9803
Mailing address:
  • Phone: 312-455-9800
  • Fax: 312-455-9803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0190225560
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: