Basic Information
| Provider Information | |||||||||
| NPI: | 1609853654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEROLD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG 38801 ACADEMIC DRIVE | ||||||||
| Address2: | SUITE B & C | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Practice Location | |||||||||
| Address1: | BLDG 38801 ACADEMIC DRIVE | ||||||||
| Address2: | SUITE B & C | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 7286 | NC | N | Dental Providers | Dentist | 122300000X | 3118 | WV | N | Dental Providers | Dentist | 1223P0300X | 7286 | NC | N | Dental Providers | Dentist | Periodontics | 1223P0300X | 3118 | WV | Y | Dental Providers | Dentist | Periodontics |
No ID Information.