Provider Demographics
NPI:1720173750
Name:BLANK, ROBERT DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DAVID
Last Name:BLANK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 N. CARTWRIGHT RD.
Mailing Address - Street 2:POB 715
Mailing Address - City:SHELTER ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11964-0715
Mailing Address - Country:US
Mailing Address - Phone:631-749-2117
Mailing Address - Fax:
Practice Address - Street 1:51A N. FERRY RD.
Practice Address - Street 2:
Practice Address - City:SHELTER ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11964-0715
Practice Address - Country:US
Practice Address - Phone:631-749-2646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248311223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics