Provider Demographics
NPI:1861588444
Name:SELDERS, ROBERT JAY JR (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAY
Last Name:SELDERS
Suffix:JR
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 COCHRANE CIR BLDG 7495
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4603
Mailing Address - Country:US
Mailing Address - Phone:719-526-2006
Mailing Address - Fax:
Practice Address - Street 1:BLDG 1002 RM 231
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121
Practice Address - Country:US
Practice Address - Phone:502-624-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12481122300000X
TN79621223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist