Provider Demographics
NPI:1275855306
Name:ROBERT C. POULSOM, D.D.S., M.S. LTD
Entity Type:Organization
Organization Name:ROBERT C. POULSOM, D.D.S., M.S. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:POULSOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS JD
Authorized Official - Phone:630-852-1020
Mailing Address - Street 1:350 SOUTH NW HIGHWAY
Mailing Address - Street 2:STE 120
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:630-852-1020
Mailing Address - Fax:630-968-9229
Practice Address - Street 1:350 SOUTH NW HIGHWAY
Practice Address - Street 2:STE 120
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:630-852-1020
Practice Address - Fax:630-968-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21.0008771223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty