Provider Demographics
NPI:1215090998
Name:WIDIS, ROBERT EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:WIDIS
Suffix:
Gender:M
Credentials:DDS
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5232 ALBEMARLE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-2659
Mailing Address - Country:US
Mailing Address - Phone:704-536-6774
Mailing Address - Fax:704-536-5998
Practice Address - Street 1:5232 ALBEMARLE RD
Practice Address - Street 2:SUITE C
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-2659
Practice Address - Country:US
Practice Address - Phone:704-536-6774
Practice Address - Fax:704-536-5998
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC50621223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics