Provider Demographics
NPI:1083281240
Name:ROBERSON, SHANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:ROBERSON
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 1:9315 CHINOOK AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-3950
Mailing Address - Country:US
Mailing Address - Phone:661-301-8869
Mailing Address - Fax:
Practice Address - Street 1:9510 HAGEMAN RD STE B
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-3953
Practice Address - Country:US
Practice Address - Phone:661-829-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist