Provider Demographics
NPI:1598875601
Name:ROBERT L DORNBOS DDS PC
Entity Type:Organization
Organization Name:ROBERT L DORNBOS DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DORNBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-649-2067
Mailing Address - Street 1:102 S MAIN
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097
Mailing Address - Country:US
Mailing Address - Phone:269-649-2067
Mailing Address - Fax:269-649-2605
Practice Address - Street 1:102 S MAIN
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097
Practice Address - Country:US
Practice Address - Phone:269-649-2067
Practice Address - Fax:269-649-2605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11549122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty