Provider Demographics
NPI:1629049317
Name:TOLLEFSON, ROBERT CORLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CORLEY
Last Name:TOLLEFSON
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 1:810 TOEPPERWEIN RD
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2306
Mailing Address - Country:US
Mailing Address - Phone:409-963-2725
Mailing Address - Fax:
Practice Address - Street 1:220 BERQUIST DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-5300
Practice Address - Country:US
Practice Address - Phone:210-292-7282
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice