Provider Demographics
NPI:1962526103
Name:DURRETT, ROBERT T (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:T
Last Name:DURRETT
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 1:1400 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-5404
Mailing Address - Country:US
Mailing Address - Phone:847-234-8608
Mailing Address - Fax:847-234-8671
Practice Address - Street 1:1400 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-5404
Practice Address - Country:US
Practice Address - Phone:847-234-8608
Practice Address - Fax:847-234-8671
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist