Provider Demographics
NPI:1235448150
Name:ROBERTSON, MARK ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:ROBERTSON
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 1:105 HUDSON DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2801
Mailing Address - Country:US
Mailing Address - Phone:423-543-5263
Mailing Address - Fax:423-543-5006
Practice Address - Street 1:105 HUDSON DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2801
Practice Address - Country:US
Practice Address - Phone:423-543-5263
Practice Address - Fax:423-543-5006
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty