Provider Demographics
NPI:1679677728
Name:BINGHAM, ROBIN T (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBIN
Middle Name:T
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 MILSTEAD AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012
Mailing Address - Country:US
Mailing Address - Phone:770-602-1138
Mailing Address - Fax:770-602-1461
Practice Address - Street 1:1380 MILSTEAD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012
Practice Address - Country:US
Practice Address - Phone:770-602-1138
Practice Address - Fax:770-602-1461
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0125171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000947042FMedicaid