Healthcare Provider Details

I. General information

NPI: 1508844242
Provider Name (Legal Business Name): ROBERT KURT FRISK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 6TH ST NHGL DENTAL DIRECTORATE
GREAT LAKES IL
60088-2833
US

IV. Provider business mailing address

1042 VILLAGE LN
GURNEE IL
60031-5604
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-2100
  • Fax:
Mailing address:
  • Phone: 847-223-6318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3918-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: