Healthcare Provider Details

I. General information

NPI: 1366683898
Provider Name (Legal Business Name): ROBERT J. SHANAHAN D.D.S., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6686 JOLIET ROAD
INDIAN HEAD PARK IL
60525
US

IV. Provider business mailing address

6686 JOLIET RD
INDIAN HEAD PARK IL
60525
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-1100
  • Fax: 708-783-1101
Mailing address:
  • Phone: 708-783-1100
  • Fax: 708-783-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19013677
License Number StateIL

VIII. Authorized Official

Name: ROBERT J SHANAHAN
Title or Position: PRESIDENT
Credential: DENTIST
Phone: 708-783-1100