Provider Demographics
NPI:1164680005
Name:MUCKEY, ROBERT L
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:MUCKEY
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 1:7171 BOWLING DRIVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823
Mailing Address - Country:US
Mailing Address - Phone:916-392-7874
Mailing Address - Fax:916-392-0614
Practice Address - Street 1:7171 BOWLING DRIVE
Practice Address - Street 2:SUITE 240
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823
Practice Address - Country:US
Practice Address - Phone:916-392-7874
Practice Address - Fax:916-392-0614
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist