Provider Demographics
NPI:1134247117
Name:HUMPHREY, ROBERT DOUGLAS JR (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:HUMPHREY
Suffix:JR
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 1:109 MTN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:RURAL RETREAT
Mailing Address - State:VA
Mailing Address - Zip Code:24368-0276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:RURAL RETREAT
Practice Address - State:VA
Practice Address - Zip Code:24368-0276
Practice Address - Country:US
Practice Address - Phone:276-686-4823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010026671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice