Provider Demographics
NPI:1578053450
Name:LANDGRAF, ROBERT TAYLOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TAYLOR
Last Name:LANDGRAF
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 1:6441 WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-2033
Mailing Address - Country:US
Mailing Address - Phone:614-866-7445
Mailing Address - Fax:
Practice Address - Street 1:4241 KIMBERLY PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-7225
Practice Address - Country:US
Practice Address - Phone:614-866-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300254241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1841200029Medicaid