Basic Information
| Provider Information | |||||||||
| NPI: | 1619162054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLLOY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9801 S PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731596925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056921222 | ||||||||
| FaxNumber: | 4057030930 | ||||||||
| Practice Location | |||||||||
| Address1: | 9801 S PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731596925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056921222 | ||||||||
| FaxNumber: | 4057030930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 01/22/2013 | ||||||||
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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 | 1223P0221X | 5436 | OK | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 100126100B | 01 | OK | OKLAHOMA HEALTHCARE AUTHO | OTHER |