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General NPI Number Information
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NPI Number | 1033377684
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Entity Type | Individual
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Provider Name | JILL RANDALL DANAHER D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 1625 SHERIDAN RD STE H
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City | WILMETTE
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State | IL
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Zip | 60091-1800
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Country | US
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Telephone | 847-634-6166
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Fax |
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Provider Business Mailing Address
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Address Line | 1143 N GREEN BAY RD
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City | LAKE FOREST
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State | IL
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Zip | 60045-1103
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Country | US
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Telephone | 203-494-5254
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 008425
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 019028106
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License Number State | IL
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