MEDICARE: DR. ROBERT EDWARD WIDIS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	5062	NC

General Provider Information

NPI Number	:	1215090998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT EDWARD WIDIS DDS

Provider Business Mailing Address
First Line	:	5232 ALBEMARLE RD
Second Line	:	SUITE C
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-2659
Country	:	US
Telephone Number	:	704-536-6774
Fax Number	:	704-536-5998

Provider Business Practice Location Address
First Line	:	5232 ALBEMARLE RD
Second Line	:	SUITE C
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-2659
Country	:	US
Telephone Number	:	704-536-6774
Fax Number	:	704-536-5998

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	07/08/2007

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