Provider Demographics
NPI:1922092329
Name:COLANTINO, ROBERT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:COLANTINO
Suffix:
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 1:997 CLOCK TOWER DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1301
Mailing Address - Country:US
Mailing Address - Phone:217-546-3371
Mailing Address - Fax:217-793-5107
Practice Address - Street 1:997 CLOCK TOWER DR
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1301
Practice Address - Country:US
Practice Address - Phone:217-546-3371
Practice Address - Fax:217-793-5107
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL611210Medicare ID - Type Unspecified
ILU30300Medicare UPIN