Provider Demographics
NPI:1184728768
Name:ROBERT W SHAFER DDS LTD
Entity type:Organization
Organization Name:ROBERT W SHAFER DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-356-9595
Mailing Address - Street 1:2902 CROSSING CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6175
Mailing Address - Country:US
Mailing Address - Phone:217-356-9595
Mailing Address - Fax:217-356-6425
Practice Address - Street 1:2902 CROSSING CT
Practice Address - Street 2:SUITE A
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6175
Practice Address - Country:US
Practice Address - Phone:217-356-9595
Practice Address - Fax:217-356-6425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190229931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19022993OtherLICENSE
IL19022993OtherLICENSE