Provider Demographics
NPI:1588753016
Name:SHULTZ, ROBERT DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DALE
Last Name:SHULTZ
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 1:8180 BURR OAK RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9009
Mailing Address - Country:US
Mailing Address - Phone:815-623-6185
Mailing Address - Fax:
Practice Address - Street 1:5640 CLAYTON CIR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9503
Practice Address - Country:US
Practice Address - Phone:815-623-7366
Practice Address - Fax:815-623-7331
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice