Provider Demographics
NPI:1275646267
Name:BERUBE, ROBERT OMER II (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:OMER
Last Name:BERUBE
Suffix:II
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 1:101 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4641
Mailing Address - Country:US
Mailing Address - Phone:906-228-6309
Mailing Address - Fax:906-228-6379
Practice Address - Street 1:101 S FRONT ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4641
Practice Address - Country:US
Practice Address - Phone:906-228-6309
Practice Address - Fax:906-228-6379
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010110091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice