Provider Demographics
NPI:1407933427
Name:MABRY, ROBERT TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TODD
Last Name:MABRY
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 1:4636 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6826
Mailing Address - Country:US
Mailing Address - Phone:260-436-9439
Mailing Address - Fax:260-436-9467
Practice Address - Street 1:4636 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6826
Practice Address - Country:US
Practice Address - Phone:260-436-9439
Practice Address - Fax:260-436-9467
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85921223E0200X
OH196541223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics