Provider Demographics
NPI:1861655631
Name:DURR, ROBERT DERELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DERELL
Last Name:DURR
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 1:20402 CRAWFORD AVE
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1734
Mailing Address - Country:US
Mailing Address - Phone:708-747-4294
Mailing Address - Fax:
Practice Address - Street 1:20402 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1734
Practice Address - Country:US
Practice Address - Phone:708-747-4294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025548332B00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies