Provider Demographics
NPI:1467684175
Name:ROBERT A EBERT, DDS
Entity Type:Organization
Organization Name:ROBERT A EBERT, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:EBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-664-2912
Mailing Address - Street 1:910 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2601
Mailing Address - Country:US
Mailing Address - Phone:208-664-2912
Mailing Address - Fax:
Practice Address - Street 1:910 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2601
Practice Address - Country:US
Practice Address - Phone:208-664-2912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000283400Medicaid
ID9200508/181205Medicaid