Provider Demographics
NPI:1033377684
Name:DANAHER, JILL RANDALL (DMD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:RANDALL
Last Name:DANAHER
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 1:1143 N GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1103
Mailing Address - Country:US
Mailing Address - Phone:203-494-5254
Mailing Address - Fax:
Practice Address - Street 1:1625 SHERIDAN RD STE H
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1800
Practice Address - Country:US
Practice Address - Phone:847-634-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0084251223X0400X
IL0190281061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics