Provider Demographics
NPI:1508960170
Name:SHAFER, ROBERT WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:SHAFER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 CROSSING CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6175
Mailing Address - Country:US
Mailing Address - Phone:217-356-9595
Mailing Address - Fax:217-356-6425
Practice Address - Street 1:2902 CROSSING CT
Practice Address - Street 2:SUITE A
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6175
Practice Address - Country:US
Practice Address - Phone:217-356-9595
Practice Address - Fax:217-356-6425
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190229931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19022993OtherORTHODONTIC LICENSE