Provider Demographics
NPI:1275892671
Name:MATTHEW E ROBERTSON DMD LLC
Entity Type:Organization
Organization Name:MATTHEW E ROBERTSON DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:316-722-0800
Mailing Address - Street 1:3510 N RIDGE RD
Mailing Address - Street 2:STE 500
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1224
Mailing Address - Country:US
Mailing Address - Phone:316-722-0800
Mailing Address - Fax:316-722-5822
Practice Address - Street 1:3510 N RIDGE RD
Practice Address - Street 2:STE 500
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1224
Practice Address - Country:US
Practice Address - Phone:316-722-0800
Practice Address - Fax:316-722-5822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS605121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200557210AMedicaid