Provider Demographics
NPI:1558415075
Name:WARD, ROBERET L (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERET
Middle Name:L
Last Name:WARD
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 1:1325 N MT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRAEDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701
Mailing Address - Country:US
Mailing Address - Phone:573-334-5566
Mailing Address - Fax:
Practice Address - Street 1:1325 N MT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRAEDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701
Practice Address - Country:US
Practice Address - Phone:573-334-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOO11080204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT83773Medicare ID - Type Unspecified