Provider Demographics
NPI:1104034222
Name:ANTOLAK, ROBERT VANCE (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:VANCE
Last Name:ANTOLAK
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 1:15055 22 MILE RD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4401
Mailing Address - Country:US
Mailing Address - Phone:586-247-3500
Mailing Address - Fax:586-247-1211
Practice Address - Street 1:15055 22 MILE RD
Practice Address - Street 2:SUITE #2
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4401
Practice Address - Country:US
Practice Address - Phone:586-247-3500
Practice Address - Fax:586-247-1211
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI146901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice