Provider Demographics
NPI:1891810198
Name:KANKE, ROBERT JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:KANKE
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 1:2010 PROGRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2475
Mailing Address - Country:US
Mailing Address - Phone:715-623-7221
Mailing Address - Fax:715-627-4548
Practice Address - Street 1:2010 PROGRESS BLVD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2475
Practice Address - Country:US
Practice Address - Phone:715-623-7221
Practice Address - Fax:715-627-4548
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33407700Medicaid