Provider Demographics
NPI:1528041597
Name:LALLAS, JUNE UPSHAW (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUNE
Middle Name:UPSHAW
Last Name:LALLAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JUNE
Other - Middle Name:ELEN
Other - Last Name:UPSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1200 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-547-1595
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-2112
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-547-1595
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190237991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019023799Medicaid