Provider Demographics
NPI:1508945437
Name:BLAKKOLB, ROBIN BRENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBIN
Middle Name:BRENT
Last Name:BLAKKOLB
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 1:6800 MAIN ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-3493
Mailing Address - Country:US
Mailing Address - Phone:630-964-5880
Mailing Address - Fax:
Practice Address - Street 1:6800 MAIN ST
Practice Address - Street 2:SUITE 106
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-3493
Practice Address - Country:US
Practice Address - Phone:630-964-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0011271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL655020Medicare ID - Type Unspecified