=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366458051
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT MICHAEL ALT DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2314 N 2ND ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52732-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-242-1565
-----------------------------------------------------
Fax | 563-242-0095
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2314 N 2ND ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52732-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-242-1565
-----------------------------------------------------
Fax | 563-242-0095
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 06659
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------