Provider Demographics
NPI:1245411578
Name:MOULTON, ROBERT G (DDS,SC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:MOULTON
Suffix:
Gender:M
Credentials:DDS,SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-1736
Mailing Address - Country:US
Mailing Address - Phone:920-674-2865
Mailing Address - Fax:920-674-2799
Practice Address - Street 1:504 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-1736
Practice Address - Country:US
Practice Address - Phone:920-674-2865
Practice Address - Fax:920-674-2799
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist