Provider Demographics
NPI:1336151463
Name:JUNGBLUT, ROBIN M (DDS)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:M
Last Name:JUNGBLUT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:493 DUANE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4501
Mailing Address - Country:US
Mailing Address - Phone:630-858-1232
Mailing Address - Fax:630-858-1299
Practice Address - Street 1:493 DUANE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4501
Practice Address - Country:US
Practice Address - Phone:630-858-1232
Practice Address - Fax:630-858-1299
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice