Provider Demographics
NPI:1396768909
Name:DIBAUDA, ROBERT JEROME (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JEROME
Last Name:DIBAUDA
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 1:6175 SOM CENTER RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2965
Mailing Address - Country:US
Mailing Address - Phone:440-349-3844
Mailing Address - Fax:440-349-3869
Practice Address - Street 1:6175 SOM CENTER RD
Practice Address - Street 2:SUITE 240
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2965
Practice Address - Country:US
Practice Address - Phone:440-349-3844
Practice Address - Fax:440-349-3869
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0154201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice