Provider Demographics
NPI:1053479626
Name:ROBERTS, RAENIE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RAENIE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 EAST PROSPER TRAIL
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078
Mailing Address - Country:US
Mailing Address - Phone:972-347-6444
Mailing Address - Fax:972-347-6408
Practice Address - Street 1:2440 EAST PROSPER TRAIL
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078
Practice Address - Country:US
Practice Address - Phone:972-347-6444
Practice Address - Fax:972-347-6408
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics