Provider Demographics
NPI:1598765604
Name:JOHN, ROBERT C (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:JOHN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 BARRINGTON PARK
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2122
Mailing Address - Country:US
Mailing Address - Phone:248-508-4641
Mailing Address - Fax:
Practice Address - Street 1:1500 W BIG BEAVER RD STE 110
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3522
Practice Address - Country:US
Practice Address - Phone:248-508-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010170241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9755066630OtherBLUE CROSS BLUE SHIELD
MI124472206Medicaid
RJ017024OtherCHAMPUS-CHAMPUS
MI104472224Medicaid
MI147805OtherGREAT LAKES HEALTH PLAN
MIU93813OtherHAP
7164521OtherAETNA
RJ017024OtherCOMMERCIAL-COMMERCIAL NUMBER