Provider Demographics
NPI:1780785550
Name:ENNIS, ROBERT L (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:ENNIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3916 S LYNN CT
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-3393
Mailing Address - Country:US
Mailing Address - Phone:816-254-2345
Mailing Address - Fax:816-254-1579
Practice Address - Street 1:3916 S. LYNN CT.
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055
Practice Address - Country:US
Practice Address - Phone:816-254-2345
Practice Address - Fax:816-254-1579
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT73701Medicare UPIN
MOB053832AMedicare ID - Type Unspecified