Healthcare Provider Details

I. General information

NPI: 1013913227
Provider Name (Legal Business Name): ROBERT DOUGLAS DENT D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E HANOVER ST
NEW BADEN IL
62265-1908
US

IV. Provider business mailing address

701 E HANOVER ST
NEW BADEN IL
62265-1908
US

V. Phone/Fax

Practice location:
  • Phone: 618-588-4976
  • Fax: 618-588-4926
Mailing address:
  • Phone: 618-588-4976
  • Fax: 618-588-4926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-004870
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: