Provider Demographics
NPI:1245304039
Name:TREVARTHEN, ROBERT JOHN (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:TREVARTHEN
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 1:315 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-3824
Mailing Address - Country:US
Mailing Address - Phone:563-263-8034
Mailing Address - Fax:
Practice Address - Street 1:315 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-3824
Practice Address - Country:US
Practice Address - Phone:563-263-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA59771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0015099Medicaid