Provider Demographics
NPI:1285713461
Name:DAVIES, ROBERT EVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EVAN
Last Name:DAVIES
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 1:2117 CORPORATE DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189
Mailing Address - Country:US
Mailing Address - Phone:262-547-5813
Mailing Address - Fax:262-547-5835
Practice Address - Street 1:2117 CORPORATE DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189
Practice Address - Country:US
Practice Address - Phone:262-547-5813
Practice Address - Fax:262-547-5835
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000400-0151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33662900Medicaid