Provider Demographics
NPI:1245383371
Name:MAIN, ROBERT JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:MAIN
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 1:2303 PAMELA DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1490
Mailing Address - Country:US
Mailing Address - Phone:618-997-2777
Mailing Address - Fax:618-997-5124
Practice Address - Street 1:1504 SIOUX DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5209
Practice Address - Country:US
Practice Address - Phone:618-997-0127
Practice Address - Fax:618-997-5124
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice