Provider Demographics
NPI:1114100120
Name:ROBERTS, DOROTHY O
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:O
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:
Other - Last Name:WHITFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-562-4461
Mailing Address - Fax:
Practice Address - Street 1:272 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-1848
Practice Address - Country:US
Practice Address - Phone:860-296-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT91781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice