Healthcare Provider Details

I. General information

NPI: 1699807537
Provider Name (Legal Business Name): ROBERT EDWARD NIST DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 TOLL GATE RD
WARWICK RI
02886-4444
US

IV. Provider business mailing address

40 TOLL GATE RD
WARWICK RI
02886-4444
US

V. Phone/Fax

Practice location:
  • Phone: 401-737-9363
  • Fax:
Mailing address:
  • Phone: 401-737-9363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberRI 27-89
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: