Healthcare Provider Details

I. General information

NPI: 1417047838
Provider Name (Legal Business Name): ROBERT MERLE WILLARD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2536 FARRAGUT DR
SPRINGFIELD IL
62704-1433
US

IV. Provider business mailing address

1408 WOODS FARM LN
SPRINGFIELD IL
62704-6431
US

V. Phone/Fax

Practice location:
  • Phone: 217-787-4455
  • Fax: 217-787-1439
Mailing address:
  • Phone: 217-546-3814
  • Fax: 217-787-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0210000923
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: