Healthcare Provider Details

I. General information

NPI: 1578554036
Provider Name (Legal Business Name): ROBERT WAXLER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 SOVEREIGN CT
MANCHESTER MO
63011-4400
US

IV. Provider business mailing address

410 SOVEREIGN CT
MANCHESTER MO
63011-4400
US

V. Phone/Fax

Practice location:
  • Phone: 636-391-0499
  • Fax:
Mailing address:
  • Phone: 636-391-0499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12402
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: