Provider Demographics
NPI:1730287616
Name:BROCKETT, ROBERT L (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:BROCKETT
Suffix:
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 1:6129 W CORPORATE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-8732
Mailing Address - Country:US
Mailing Address - Phone:352-795-4994
Mailing Address - Fax:352-795-4609
Practice Address - Street 1:6129 W CORPORATE OAKS DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-8732
Practice Address - Country:US
Practice Address - Phone:352-795-4994
Practice Address - Fax:352-795-4609
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 88101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073131500Medicaid
FL073131500Medicaid
FLT96441Medicare UPIN