Provider Demographics
NPI:1063586550
Name:SPRAGUE, ROBERT ELLSWORTH (DDS)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ELLSWORTH
Last Name:SPRAGUE
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 1:110 SHERIFF ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944
Mailing Address - Country:US
Mailing Address - Phone:217-466-3465
Mailing Address - Fax:
Practice Address - Street 1:110 SHERIFF ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944
Practice Address - Country:US
Practice Address - Phone:217-466-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003837Medicaid