Provider Demographics
NPI:1326504325
Name:ROBERTO V PISCHEK DMD PC
Entity Type:Organization
Organization Name:ROBERTO V PISCHEK DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:PISCHEK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-947-5811
Mailing Address - Street 1:21400 STATE HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:ROBERTSDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36567-3714
Mailing Address - Country:US
Mailing Address - Phone:251-947-5811
Mailing Address - Fax:251-945-1057
Practice Address - Street 1:21400 STATE HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567-3714
Practice Address - Country:US
Practice Address - Phone:251-947-5811
Practice Address - Fax:251-945-1057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009969910Medicaid