Healthcare Provider Details

I. General information

NPI: 1598875601
Provider Name (Legal Business Name): ROBERT L DORNBOS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S MAIN
VICKSBURG MI
49097
US

IV. Provider business mailing address

102 S MAIN
VICKSBURG MI
49097
US

V. Phone/Fax

Practice location:
  • Phone: 269-649-2067
  • Fax: 269-649-2605
Mailing address:
  • Phone: 269-649-2067
  • Fax: 269-649-2605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11549
License Number StateMI

VIII. Authorized Official

Name: ROBERT LEE DORNBOS
Title or Position: PRESIDENT
Credential: DDS
Phone: 269-649-2067