Provider Demographics
NPI:1265817753
Name:ROBERTSON, RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
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 1:13109 VILLA MONTANA WAY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732-1634
Mailing Address - Country:US
Mailing Address - Phone:512-576-7254
Mailing Address - Fax:
Practice Address - Street 1:7800 SOUTHWEST PKWY
Practice Address - Street 2:UNIT 1811
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-6113
Practice Address - Country:US
Practice Address - Phone:512-576-7254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-25
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice