Provider Demographics
NPI:1407914096
Name:MOLL, ROBERT H (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:MOLL
Suffix:
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 1:940 RICHARD ROAD
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1936
Mailing Address - Country:US
Mailing Address - Phone:219-865-0940
Mailing Address - Fax:219-865-0941
Practice Address - Street 1:940 RICHARD ROAD
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1936
Practice Address - Country:US
Practice Address - Phone:219-865-0940
Practice Address - Fax:219-865-0941
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1223G0001X
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003022Medicaid