Provider Demographics
NPI:1225044282
Name:ROBERTS, GARY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:ROBERTS
Suffix:
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 1:8510 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6119
Mailing Address - Country:US
Mailing Address - Phone:318-869-3111
Mailing Address - Fax:318-869-3187
Practice Address - Street 1:8510 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6119
Practice Address - Country:US
Practice Address - Phone:318-869-3111
Practice Address - Fax:318-869-3187
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA31961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice