Provider Demographics
NPI:1386680734
Name:ANTHONY, ROBERT
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:ANTHONY
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:PO BOX 1352
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30112-0025
Mailing Address - Country:US
Mailing Address - Phone:770-834-4075
Mailing Address - Fax:
Practice Address - Street 1:606 S GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3128
Practice Address - Country:US
Practice Address - Phone:706-882-5551
Practice Address - Fax:706-812-8558
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000177262AMedicaid