Provider Demographics
NPI:1043866049
Name:ROBERTS, CELESTE
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 N WINNEBAGO DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WINNEBAGO
Mailing Address - State:MO
Mailing Address - Zip Code:64034-9319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 TOMCAT BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23460-2218
Practice Address - Country:US
Practice Address - Phone:757-953-3925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019030279122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist