Healthcare Provider Details

I. General information

NPI: 1922178359
Provider Name (Legal Business Name): ROBERT PATRICK SEWELL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE RD
DULCE NM
87528
US

IV. Provider business mailing address

12000 STONE LAKE ROAD
DULCE NM
87528
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-7211
  • Fax:
Mailing address:
  • Phone: 505-759-7211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7937
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: