Provider Demographics
NPI:1912069204
Name:HUMPHRIES, ROBERT M (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:HUMPHRIES
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 GLENKERRY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-0718
Mailing Address - Country:US
Mailing Address - Phone:269-329-0888
Mailing Address - Fax:
Practice Address - Street 1:3801 GLENKERRY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0718
Practice Address - Country:US
Practice Address - Phone:269-329-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010140931223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics