Provider Demographics
NPI:1205057866
Name:BIRDWELL, ROBERT LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
Last Name:BIRDWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6924 W. ABRAHAM LANE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AS
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:602-417-4198
Mailing Address - Fax:
Practice Address - Street 1:6924 W. ABRAHAM LANE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AS
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:602-417-4198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice