Provider Demographics
NPI:1114023736
Name:ROBERTS, SUSAN MERLENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MERLENE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MERLENE
Other - Last Name:ROBERTS GEDDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6650 N BEACH
Mailing Address - Street 2:#118
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137
Mailing Address - Country:US
Mailing Address - Phone:817-656-3999
Mailing Address - Fax:817-656-7862
Practice Address - Street 1:6650 N BEACH
Practice Address - Street 2:#118
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137
Practice Address - Country:US
Practice Address - Phone:817-656-3999
Practice Address - Fax:817-656-7862
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX155871223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry