Provider Demographics
NPI:1174617633
Name:MCMAHON, ROBERT E (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
Last Name:MCMAHON
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 1:8691 CONNECTICUT STREET
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6287
Mailing Address - Country:US
Mailing Address - Phone:219-757-5700
Mailing Address - Fax:219-757-5706
Practice Address - Street 1:502 WALL STREET
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2564
Practice Address - Country:US
Practice Address - Phone:219-462-5117
Practice Address - Fax:219-464-7351
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120076951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT34730Medicare UPIN
IN38508BMedicare ID - Type Unspecified