Provider Demographics
NPI:1164909982
Name:ROBERTSON, WESLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2979 W SCHOOL HOUSE LN APT 214
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-5314
Mailing Address - Country:US
Mailing Address - Phone:717-919-9501
Mailing Address - Fax:
Practice Address - Street 1:8355 LORETTO AVE STE 104
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-1830
Practice Address - Country:US
Practice Address - Phone:215-745-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist