=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598765604
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT C. JOHN D.D.S., M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2005
-----------------------------------------------------
Last Update Date | 09/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 W BIG BEAVER RD STE 110
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48084-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-508-4641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 598 BARRINGTON PARK
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48304-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-508-4641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 2901017024
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------