Provider Demographics
NPI:1124041652
Name:VANWYCK, ROBERT JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JACOB
Last Name:VANWYCK
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 1:98 WEST STREET
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759
Mailing Address - Country:US
Mailing Address - Phone:860-567-8684
Mailing Address - Fax:
Practice Address - Street 1:98 WEST ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759
Practice Address - Country:US
Practice Address - Phone:860-567-8684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT58811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice