Provider Demographics
NPI:1134212095
Name:ISMAN, ROBERT ELLIOTT (DDS, MPH)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ELLIOTT
Last Name:ISMAN
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 HUERTA PL
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-0271
Mailing Address - Country:US
Mailing Address - Phone:530-758-1456
Mailing Address - Fax:775-254-4491
Practice Address - Street 1:11155 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-6096
Practice Address - Country:US
Practice Address - Phone:916-464-3794
Practice Address - Fax:916-464-3783
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA211431223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB21143Medicaid
CAB2114301Medicaid