Provider Demographics
NPI:1598731655
Name:MONGRAIN, ROBERT BLAINE JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BLAINE
Last Name:MONGRAIN
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8701 S GARNETT RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8852
Mailing Address - Country:US
Mailing Address - Phone:918-250-9528
Mailing Address - Fax:918-250-9529
Practice Address - Street 1:8701 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8852
Practice Address - Country:US
Practice Address - Phone:918-250-9528
Practice Address - Fax:918-250-9529
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK43011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice