Provider Demographics
NPI:1962620088
Name:TREVISON, ROBIN (DMD)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:TREVISON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1679
Mailing Address - Country:US
Mailing Address - Phone:815-634-4999
Mailing Address - Fax:815-634-0014
Practice Address - Street 1:645 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1679
Practice Address - Country:US
Practice Address - Phone:815-634-4999
Practice Address - Fax:815-634-0014
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice