Provider Demographics
NPI:1497806384
Name:BLAU, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BLAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 MILL CIR UNIT 305
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-4208
Mailing Address - Country:US
Mailing Address - Phone:630-213-3636
Mailing Address - Fax:
Practice Address - Street 1:774 W BARTLETT RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103
Practice Address - Country:US
Practice Address - Phone:630-213-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics