Provider Demographics
NPI:1114016573
Name:ULLOA, ROGOBERTO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGOBERTO
Middle Name:
Last Name:ULLOA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-1706
Mailing Address - Country:US
Mailing Address - Phone:815-724-0500
Mailing Address - Fax:815-724-0583
Practice Address - Street 1:500 N CHICAGO ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-1706
Practice Address - Country:US
Practice Address - Phone:815-724-0500
Practice Address - Fax:815-724-0583
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190261921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice