Provider Demographics
NPI:1225189970
Name:LAVINE, ROBERT (DD,S)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LAVINE
Suffix:
Gender:M
Credentials:DD,S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 E 14 MILE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5963
Mailing Address - Country:US
Mailing Address - Phone:586-979-0111
Mailing Address - Fax:586-979-2412
Practice Address - Street 1:2791 E 14 MILE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5963
Practice Address - Country:US
Practice Address - Phone:586-979-0111
Practice Address - Fax:586-979-2412
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID0859405OtherBLUE CROSS OF MICHIGAN