Provider Demographics
NPI:1356969257
Name:OBENAUF, GARRETT DAVID (DMD)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:DAVID
Last Name:OBENAUF
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 1:998 CASTLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-4106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1109 W PARK AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2552
Practice Address - Country:US
Practice Address - Phone:847-367-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019032778122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist