Provider Demographics
NPI:1285820720
Name:ROBERTS, BRIAN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
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:PO BOX 1660
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-0752
Mailing Address - Country:US
Mailing Address - Phone:360-736-8380
Mailing Address - Fax:360-736-2192
Practice Address - Street 1:2409 BORST AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1411
Practice Address - Country:US
Practice Address - Phone:360-736-8380
Practice Address - Fax:360-736-2192
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA81921223G0001X
WA51511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA606932OtherUNITED CONCORDIA
WA5038930OtherDSHS