Basic Information
Provider Information | |||||||||
NPI: | 1861588444 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SELDERS | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | JAY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | D.M.D., M.S.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1667 COCHRANE CIR BLDG 7495 | ||||||||
Address2: |   | ||||||||
City: | FORT CARSON | ||||||||
State: | CO | ||||||||
PostalCode: | 809134603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195262006 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | BLDG 1002 RM 231 | ||||||||
Address2: |   | ||||||||
City: | FORT KNOX | ||||||||
State: | KY | ||||||||
PostalCode: | 40121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026242966 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 07/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 12481 | GA | N |   | Dental Providers | Dentist |   | 1223P0300X | 7962 | TN | Y |   | Dental Providers | Dentist | Periodontics |
No ID Information.