Provider Demographics
NPI:1609853654
Name:HEROLD, ROBERT WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:HEROLD
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:BLDG 38801 ACADEMIC DRIVE
Mailing Address - Street 2:SUITE B & C
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5660
Mailing Address - Country:US
Mailing Address - Phone:706-787-6927
Mailing Address - Fax:706-787-2082
Practice Address - Street 1:BLDG 38801 ACADEMIC DRIVE
Practice Address - Street 2:SUITE B & C
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5660
Practice Address - Country:US
Practice Address - Phone:706-787-6927
Practice Address - Fax:706-787-2082
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7286122300000X, 1223P0300X
WV3118122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist