Provider Demographics
NPI:1679781389
Name:PROSPERE, ROBERT NIXON (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:NIXON
Last Name:PROSPERE
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 1:710 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-2359
Mailing Address - Country:US
Mailing Address - Phone:601-442-4318
Mailing Address - Fax:601-445-9871
Practice Address - Street 1:710 N PEARL ST
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-2359
Practice Address - Country:US
Practice Address - Phone:601-442-4318
Practice Address - Fax:601-445-9871
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1729 76122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660378Medicaid
MS1729 76OtherMS DENTAL LICENSE NUMBER