Provider Demographics
NPI:1831463355
Name:LESAGE, ROBERT THOMAS JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:THOMAS
Last Name:LESAGE
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 1:815 N GALENA AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1518
Mailing Address - Country:US
Mailing Address - Phone:815-288-1418
Mailing Address - Fax:
Practice Address - Street 1:815 N GALENA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1518
Practice Address - Country:US
Practice Address - Phone:815-288-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A13394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist