Provider Demographics
NPI:1255581195
Name:WANKER, ROBERT LEWIS (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEWIS
Last Name:WANKER
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 1:9 WAYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1153
Mailing Address - Country:US
Mailing Address - Phone:304-293-4301
Mailing Address - Fax:304-293-2859
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:WVU SCHOOL OF DENTISTRY ROOM 1034
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-9404
Practice Address - Country:US
Practice Address - Phone:304-293-4301
Practice Address - Fax:304-293-2859
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1991122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice