MEDICARE: DR. ROBERT LOUIS O'DONNELL JR. DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2901022833	MI

General Provider Information

NPI Number	:	1821563115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT LOUIS O'DONNELL JR. DDS

Provider Business Mailing Address
First Line	:	3535 FERNDALE AVE
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61834-7325
Country	:	US
Telephone Number	:	217-779-0400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 W SIDNEY RD
Second Line	:
City	:	SIDNEY
State	:	MI
Zip	:	48885-9748
Country	:	US
Telephone Number	:	877-328-0777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2018
Last Update Date	:	10/12/2018

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