Robert Blackwell
Individual provider Active NPI Dentist · Brookfield, IL
NPI 1205964137 · NPPES record last updated Apr 10, 2014
Key facts
- NPI
- 1205964137
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 019018706 (IL)
- Practice address
- 3631 Forest Ave
Unit D
Brookfield, IL 60513-1763 - Phone
- (217) 621-3232
- NPI assigned
- Mar 1, 2007
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019018706 | IL | MD | Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019018706 | IL | Yes |
Addresses
Primary practice location
3631 Forest Ave
Unit D
Brookfield, IL 60513-1763
Mailing address
3631 Forest Ave
Unit D
Brookfield, IL 60513-1763
Phone (217) 621-3232
Other providers in Brookfield, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 10, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.