Provider Demographics
NPI:1609846617
Name:MABERRY, JR., ROBERT TRUITT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TRUITT
Last Name:MABERRY, JR.
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 1:3980 BOAT CLUB RD.
Mailing Address - Street 2:#114
Mailing Address - City:FT. WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135
Mailing Address - Country:US
Mailing Address - Phone:817-237-1600
Mailing Address - Fax:817-237-2604
Practice Address - Street 1:3980 BOAT CLUB RD.
Practice Address - Street 2:STE. 114
Practice Address - City:FT. WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135
Practice Address - Country:US
Practice Address - Phone:817-237-1600
Practice Address - Fax:817-237-2604
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice