Provider Demographics
NPI:1003904806
Name:ROBERTSON, FOREST RICHARD II (DDS)
Entity Type:Individual
Prefix:
First Name:FOREST
Middle Name:RICHARD
Last Name:ROBERTSON
Suffix:II
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 1:801 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-2532
Mailing Address - Country:US
Mailing Address - Phone:574-583-5100
Mailing Address - Fax:
Practice Address - Street 1:515 S ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960
Practice Address - Country:US
Practice Address - Phone:574-583-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN76531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice