Healthcare Provider Details

I. General information

NPI: 1942752837
Provider Name (Legal Business Name): ROBERT KEMP VAN WAGENEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VIA GIORGIO CORBETTA
VICENZA VI
36100
IT

IV. Provider business mailing address

VIA GIORGIO CORBETTA, 17
VICENZA VI
36100
IT

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00202992
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: