Healthcare Provider Details

I. General information

NPI: 1063826386
Provider Name (Legal Business Name): ROBERT B DAVIDSON DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2014
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 N MAIN ST
ELBURN IL
60119-9103
US

IV. Provider business mailing address

708 N MAIN ST P.O. BOX 8031
ELBURN IL
60119-9103
US

V. Phone/Fax

Practice location:
  • Phone: 630-365-6127
  • Fax: 630-365-6128
Mailing address:
  • Phone: 630-365-6127
  • Fax: 630-365-6128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.021402
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT BRUCE DAVIDSON
Title or Position: OWNER
Credential: D.D.S.
Phone: 630-365-6127