Provider Demographics
NPI:1306155163
Name:UNDERILL, ROBERT WILLARD JR (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLARD
Last Name:UNDERILL
Suffix:JR
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 1:2156 JULIAN AVE NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4020
Mailing Address - Country:US
Mailing Address - Phone:321-724-9300
Mailing Address - Fax:321-727-8361
Practice Address - Street 1:2156 JULIAN AVE NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4020
Practice Address - Country:US
Practice Address - Phone:321-724-9300
Practice Address - Fax:321-727-8361
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 8803122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist