Healthcare Provider Details

I. General information

NPI: 1780785550
Provider Name (Legal Business Name): ROBERT L ENNIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 S. LYNN CT.
INDEPENDENCE MO
64055
US

IV. Provider business mailing address

3916 S LYNN CT
INDEPENDENCE MO
64055-3393
US

V. Phone/Fax

Practice location:
  • Phone: 816-254-2345
  • Fax: 816-254-1579
Mailing address:
  • Phone: 816-254-2345
  • Fax: 816-254-1579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11438
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: