Provider Demographics
NPI:1922174648
Name:IMM, ROBERT DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DAVID
Last Name:IMM
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 1:318 N SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487
Mailing Address - Country:US
Mailing Address - Phone:715-453-4344
Mailing Address - Fax:715-453-3011
Practice Address - Street 1:318 N SIXTH ST
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487
Practice Address - Country:US
Practice Address - Phone:715-453-4344
Practice Address - Fax:715-453-3011
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49130151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33742400Medicaid
WI4913015OtherLICENSE
WI4913015OtherLICENSE