Provider Demographics
NPI:1154663573
Name:DEITZ, ROBERT MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:DEITZ
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 1:272 NEW SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3116
Mailing Address - Country:US
Mailing Address - Phone:518-944-0986
Mailing Address - Fax:
Practice Address - Street 1:272 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3116
Practice Address - Country:US
Practice Address - Phone:518-944-0986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-24
Last Update Date:2013-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist