Provider Demographics
NPI:1710090865
Name:GILLIAM, ROBERT NATHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:NATHAN
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 HAMILTON RD
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:FT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-442-3905
Mailing Address - Fax:580-442-4002
Practice Address - Street 1:652 HAMILTON RD
Practice Address - Street 2:USA DENTAC
Practice Address - City:FT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503
Practice Address - Country:US
Practice Address - Phone:580-442-3905
Practice Address - Fax:580-442-4002
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010597122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist