Provider Demographics
NPI:1154478253
Name:VANEENWYK, ROBERT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:VANEENWYK
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 1:26 S LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:BERGEN
Mailing Address - State:NY
Mailing Address - Zip Code:14416-9734
Mailing Address - Country:US
Mailing Address - Phone:585-494-1145
Mailing Address - Fax:
Practice Address - Street 1:26 S LAKE AVE
Practice Address - Street 2:
Practice Address - City:BERGEN
Practice Address - State:NY
Practice Address - Zip Code:14416-9734
Practice Address - Country:US
Practice Address - Phone:585-494-1145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0332421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice