Provider Demographics
NPI:1174668644
Name:COREY A. ROBERTSON, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:COREY A. ROBERTSON, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-201-0511
Mailing Address - Street 1:9745 AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8101
Mailing Address - Country:US
Mailing Address - Phone:225-201-0511
Mailing Address - Fax:
Practice Address - Street 1:9745 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8101
Practice Address - Country:US
Practice Address - Phone:225-201-0511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty