Provider Demographics
NPI:1225109374
Name:ROBERTSON, WILLIAM DOUGLAS (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1025 MAIN ST
Mailing Address - Street 2:604 MULL CENTER
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2726
Mailing Address - Country:US
Mailing Address - Phone:304-233-4851
Mailing Address - Fax:304-233-4852
Practice Address - Street 1:1025 MAIN ST
Practice Address - Street 2:604 MULL CENTER
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-2726
Practice Address - Country:US
Practice Address - Phone:304-233-4851
Practice Address - Fax:304-233-4852
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25981223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0138723000Medicaid