Provider Demographics
NPI:1164972352
Name:ROBERTSON FAMILY DENTAL
Entity Type:Organization
Organization Name:ROBERTSON FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-874-6885
Mailing Address - Street 1:3112 LEXINGTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1167
Mailing Address - Country:US
Mailing Address - Phone:317-874-6892
Mailing Address - Fax:
Practice Address - Street 1:138 W ANGELA BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1101
Practice Address - Country:US
Practice Address - Phone:317-874-6885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011017A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty