Provider Demographics
NPI:1689744054
Name:POULSOM, ROBERT COLIN (DDS, MS, JD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:COLIN
Last Name:POULSOM
Suffix:
Gender:M
Credentials:DDS, MS, JD
Other - Prefix:
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Mailing Address - Street 1:6800 MAIN ST
Mailing Address - Street 2:STE 206
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-3493
Mailing Address - Country:US
Mailing Address - Phone:630-852-1020
Mailing Address - Fax:630-968-9229
Practice Address - Street 1:6800 MAIN ST
Practice Address - Street 2:STE 206
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-3493
Practice Address - Country:US
Practice Address - Phone:630-852-1020
Practice Address - Fax:630-968-9229
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics