Provider Demographics
NPI:1164588802
Name:ROBERTS, JEFFERY A (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 S EMERSON AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-2600
Mailing Address - Country:US
Mailing Address - Phone:317-536-1365
Mailing Address - Fax:317-536-1367
Practice Address - Street 1:5955 S EMERSON AVE
Practice Address - Street 2:STE. 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-2600
Practice Address - Country:US
Practice Address - Phone:317-536-1365
Practice Address - Fax:317-536-1367
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010722A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics