Provider Demographics
NPI:1003899733
Name:EGGLESTON, ROBERT L (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:EGGLESTON
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 1:3100 IVANREST AVE SW
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2930
Mailing Address - Country:US
Mailing Address - Phone:616-538-3060
Mailing Address - Fax:616-538-3653
Practice Address - Street 1:3100 IVANREST AVE SW
Practice Address - Street 2:SUITE 105
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2930
Practice Address - Country:US
Practice Address - Phone:616-538-3060
Practice Address - Fax:616-538-3653
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016314122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist