Provider Demographics
NPI:1821178617
Name:WHITTAKER, ROBERT (DMD, MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E MILLER RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1252
Mailing Address - Country:US
Mailing Address - Phone:815-625-4790
Mailing Address - Fax:
Practice Address - Street 1:10 W 3RD ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-3503
Practice Address - Country:US
Practice Address - Phone:815-625-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL045382OtherHEALTH ALLIANCE PLAN
IL9815737OtherBLUE CROSS BLUE SHIELD
G59949Medicare UPIN