Provider Demographics
NPI:1609084706
Name:CRISHAM, JOHN BRIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRIAN
Last Name:CRISHAM
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 1:2934 S LOWDEN RD
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-9101
Mailing Address - Country:US
Mailing Address - Phone:815-732-2787
Mailing Address - Fax:
Practice Address - Street 1:1307 W WASHINGTON ST
Practice Address - Street 2:SUITE 130
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061-1022
Practice Address - Country:US
Practice Address - Phone:815-732-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice