Provider Demographics
NPI:1790793313
Name:CAVANAUGH, ROBERT KYLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KYLE
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:800 WALL ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2564
Mailing Address - Country:US
Mailing Address - Phone:219-476-4110
Mailing Address - Fax:219-476-9042
Practice Address - Street 1:800 WALL ST
Practice Address - Street 2:SUITE A
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2564
Practice Address - Country:US
Practice Address - Phone:219-476-4110
Practice Address - Fax:219-476-2042
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-07-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN12010044A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics