Provider Demographics
NPI:1467930974
Name:PEMBERTON, ROBERT ORSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ORSON
Last Name:PEMBERTON
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 1:1642 US HIGHWAY 131
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8339
Mailing Address - Country:US
Mailing Address - Phone:231-622-2074
Mailing Address - Fax:
Practice Address - Street 1:1642 US HIGHWAY 131
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8339
Practice Address - Country:US
Practice Address - Phone:231-347-4662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010227951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice