Provider Demographics
NPI:1568510998
Name:HERRICK, ROBERT BRADLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRADLEY
Last Name:HERRICK
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 1:274 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1296
Mailing Address - Country:US
Mailing Address - Phone:606-886-1095
Mailing Address - Fax:606-886-0221
Practice Address - Street 1:274 S LAKE DR
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1296
Practice Address - Country:US
Practice Address - Phone:606-886-1095
Practice Address - Fax:606-886-0221
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY54351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60054350Medicaid