Healthcare Provider Details

I. General information

NPI: 1417952532
Provider Name (Legal Business Name): ROGER LANCE ROBBINS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 OLD ORCHARD CTR STE 528
SKOKIE IL
60077-1440
US

IV. Provider business mailing address

64 OLD ORCHARD CTR STE 528
SKOKIE IL
60077-1440
US

V. Phone/Fax

Practice location:
  • Phone: 847-675-3311
  • Fax: 847-674-3133
Mailing address:
  • Phone: 847-675-3311
  • Fax: 847-674-3133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19-16406
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: