Basic Information
| Provider Information | |||||||||
| NPI: | 1710090865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLIAM | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | NATHAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 652 HAMILTON RD | ||||||||
| Address2: | USA DENTAC | ||||||||
| City: | FT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | 5804424002 | ||||||||
| Practice Location | |||||||||
| Address1: | 652 HAMILTON RD | ||||||||
| Address2: | USA DENTAC | ||||||||
| City: | FT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | 5804424002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/27/2015 | ||||||||
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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 | DE00010597 | WA | N | Dental Providers | Dentist | 1223E0200X | DE00010597 | WA | Y | Dental Providers | Dentist | Endodontics |
No ID Information.