Healthcare Provider Details

I. General information

NPI: 1013086453
Provider Name (Legal Business Name): ROBERT W ASTLES DMD MAGD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GRANDE BLVD SE STE A
RIO RANCHO NM
87124-1695
US

IV. Provider business mailing address

963 37TH PLACE
VERO BEACH FL
32960
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-1500
  • Fax:
Mailing address:
  • Phone: 772-562-5700
  • Fax: 772-562-5799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7197
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: