Provider Demographics
NPI:1942652086
Name:POULARD, ROBERT BARTHOLOMEW
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BARTHOLOMEW
Last Name:POULARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4566 OKLAHOMA AVE
Mailing Address - Street 2:BLDG 2100
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-1638
Mailing Address - Country:US
Mailing Address - Phone:573-596-2903
Mailing Address - Fax:
Practice Address - Street 1:4566 OKLAHOMA AVE
Practice Address - Street 2:BLDG 2100
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-1638
Practice Address - Country:US
Practice Address - Phone:573-596-2903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant