Provider Demographics
NPI:1982684916
Name:DORNBOS, ROBERT L (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:DORNBOS
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 1:102 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-1211
Mailing Address - Country:US
Mailing Address - Phone:269-649-2067
Mailing Address - Fax:269-649-2605
Practice Address - Street 1:102 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-1211
Practice Address - Country:US
Practice Address - Phone:269-649-2067
Practice Address - Fax:269-649-2605
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI115491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice