Provider Demographics
NPI:1982679015
Name:DAW, JOSEPH JR (MD, DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:DAW
Suffix:JR
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E DEVON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-2639
Mailing Address - Country:US
Mailing Address - Phone:864-625-3376
Mailing Address - Fax:
Practice Address - Street 1:550 E DEVON AVE STE 200
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-2639
Practice Address - Country:US
Practice Address - Phone:864-625-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020141204E00000X
IL0360975452086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097545Medicaid