Healthcare Provider Details

I. General information

NPI: 1093718645
Provider Name (Legal Business Name): ROBERT CARL WUNDERLE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD BLDG H
MARIETTA GA
30068-5518
US

IV. Provider business mailing address

1000 JOHNSON FERRY RD BLDG H
MARIETTA GA
30068-5518
US

V. Phone/Fax

Practice location:
  • Phone: 770-977-0364
  • Fax: 678-819-6531
Mailing address:
  • Phone: 770-977-0364
  • Fax: 678-819-6531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN008930
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: