Provider Demographics
NPI:1821563115
Name:O'DONNELL, ROBERT LOUIS JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LOUIS
Last Name:O'DONNELL
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 FERNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-7325
Mailing Address - Country:US
Mailing Address - Phone:217-779-0400
Mailing Address - Fax:
Practice Address - Street 1:1550 W SIDNEY RD
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:MI
Practice Address - Zip Code:48885-9748
Practice Address - Country:US
Practice Address - Phone:877-328-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022833122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist