Provider Demographics
NPI:1104946193
Name:LEGAN, ROBERT FRANK (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:FRANK
Last Name:LEGAN
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 1:15642 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5611
Mailing Address - Country:US
Mailing Address - Phone:216-521-5482
Mailing Address - Fax:216-521-5482
Practice Address - Street 1:15642 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5611
Practice Address - Country:US
Practice Address - Phone:216-521-5482
Practice Address - Fax:216-521-5482
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-142101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0513939Medicaid