Provider Demographics
NPI:1417026618
Name:HARRELL, ROBERT COLLINS (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:COLLINS
Last Name:HARRELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 CALLE AMANECER
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6274
Mailing Address - Country:US
Mailing Address - Phone:949-498-1320
Mailing Address - Fax:
Practice Address - Street 1:905 CALLE AMANECER
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6274
Practice Address - Country:US
Practice Address - Phone:949-498-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA477261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice