Provider Demographics
NPI:1548373913
Name:BROWN, ROBERT LESLIE (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LESLIE
Last Name:BROWN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-3052
Mailing Address - Country:US
Mailing Address - Phone:803-276-9343
Mailing Address - Fax:
Practice Address - Street 1:1504 WILSON RD
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-3052
Practice Address - Country:US
Practice Address - Phone:803-276-9343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2158122300000X
GA304DT122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC21584Medicaid