Provider Demographics
NPI:1558336883
Name:DANIELS, ROBERT W (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:DANIELS
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:STATE ROAD 75 - HOUSE #15136
Mailing Address - Street 2:P.O. BOX 516
Mailing Address - City:PENASCO
Mailing Address - State:NM
Mailing Address - Zip Code:87553
Mailing Address - Country:US
Mailing Address - Phone:505-587-2809
Mailing Address - Fax:505-587-1944
Practice Address - Street 1:111 N RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2627
Practice Address - Country:US
Practice Address - Phone:505-753-7218
Practice Address - Fax:505-753-5815
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD26341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice