Provider Demographics
NPI:1689906331
Name:WAKE, ROBERT III (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:WAKE
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 MEDICAL GROUP
Mailing Address - Street 2:149 HART ST
Mailing Address - City:SAFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311-3482
Mailing Address - Country:US
Mailing Address - Phone:312-676-4744
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:NY
Practice Address - Zip Code:96368-0100
Practice Address - Country:US
Practice Address - Phone:315-630-4395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-10049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist