Provider Demographics
NPI:1558488155
Name:ROSENBLATT, RICHARD GARY (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GARY
Last Name:ROSENBLATT
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 1:1911 CAVELL AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2216
Mailing Address - Country:US
Mailing Address - Phone:847-579-1247
Mailing Address - Fax:
Practice Address - Street 1:1400 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-5404
Practice Address - Country:US
Practice Address - Phone:847-234-4405
Practice Address - Fax:847-234-4585
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190249621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208034070OtherEIN #