MEDICARE: ROBERT BARTHOLOMEW POULARD

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	126800000X	Dental Assistant

General Provider Information

NPI Number	:	1942652086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT BARTHOLOMEW POULARD

Provider Business Mailing Address
First Line	:	4566 OKLAHOMA AVE
Second Line	:	BLDG 2100
City	:	FORT LEONARD WOOD
State	:	MO
Zip	:	65473-1638
Country	:	US
Telephone Number	:	573-596-2903
Fax Number	:

Provider Business Practice Location Address
First Line	:	4566 OKLAHOMA AVE
Second Line	:	BLDG 2100
City	:	FORT LEONARD WOOD
State	:	MO
Zip	:	65473-1638
Country	:	US
Telephone Number	:	573-596-2903
Fax Number	:

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

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	07/12/2016

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