Provider Demographics
NPI:1952599573
Name:WALLOCK, ROBERT A
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:WALLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12720 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4637
Mailing Address - Country:US
Mailing Address - Phone:262-784-0053
Mailing Address - Fax:
Practice Address - Street 1:12720 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4637
Practice Address - Country:US
Practice Address - Phone:262-784-0053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4138-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366586224OtherTYPE 2 NPI
U51056Medicare UPIN
1366586224OtherTYPE 2 NPI