Provider Demographics
NPI:1730294075
Name:DWYER, ROBERT ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALLEN
Last Name:DWYER
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 1:2112 BLACK AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-1339
Mailing Address - Country:US
Mailing Address - Phone:715-379-1718
Mailing Address - Fax:
Practice Address - Street 1:2112 BLACK AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-1339
Practice Address - Country:US
Practice Address - Phone:715-379-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA33396400Medicaid