Provider Demographics
NPI:1912013103
Name:PROUGH, ROBERT J (DDS PA)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:PROUGH
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 VANTAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401
Mailing Address - Country:US
Mailing Address - Phone:254-965-2541
Mailing Address - Fax:254-965-4531
Practice Address - Street 1:605 VANTAGE DRIVE
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401
Practice Address - Country:US
Practice Address - Phone:254-965-2541
Practice Address - Fax:254-965-4531
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD115241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX759508OtherUNITED CONCORDIA PROVIDER
T15377Medicare UPIN