Provider Demographics
NPI:1114076718
Name:ROBERTS, JESSE HENTON JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:HENTON
Last Name:ROBERTS
Suffix:JR
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 1:436 HAILE RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:LA
Mailing Address - Zip Code:71226-9554
Mailing Address - Country:US
Mailing Address - Phone:318-255-9440
Mailing Address - Fax:318-251-1270
Practice Address - Street 1:702 N TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3324
Practice Address - Country:US
Practice Address - Phone:318-255-9440
Practice Address - Fax:318-251-1270
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA35861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice