Provider Demographics
NPI:1053471961
Name:WHEATLEY, ROBERT THOMAS
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:THOMAS
Last Name:WHEATLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 S 5TH ST STE 270
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2446
Mailing Address - Country:US
Mailing Address - Phone:636-940-2543
Mailing Address - Fax:636-947-6080
Practice Address - Street 1:1360 S 5TH ST STE 270
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301
Practice Address - Country:US
Practice Address - Phone:636-940-2543
Practice Address - Fax:636-947-6080
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022027122300000X, 1223G0001X
MO0143471223G0001X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies