Provider Demographics
NPI:1144756099
Name:ROBERTSON, CHARLES LEONARD JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LEONARD
Last Name:ROBERTSON
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 1:1690 S OHIO ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-3317
Mailing Address - Country:US
Mailing Address - Phone:765-342-8435
Mailing Address - Fax:
Practice Address - Street 1:1690 S OHIO ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-3317
Practice Address - Country:US
Practice Address - Phone:765-342-8435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007059A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist