Provider Demographics
NPI:1770192197
Name:SPARKS, ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:SPARKS
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 1:4231 AUDUBON OAKS CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-5938
Mailing Address - Country:US
Mailing Address - Phone:405-365-0557
Mailing Address - Fax:
Practice Address - Street 1:7255 KATHLEEN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-4722
Practice Address - Country:US
Practice Address - Phone:863-808-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN253261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice