Provider Demographics
NPI:1295837508
Name:ROBERTS, CLINTON LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:LAWRENCE
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 1:13942 GRAND OAKS CT.
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425
Mailing Address - Country:US
Mailing Address - Phone:218-746-4555
Mailing Address - Fax:218-746-4558
Practice Address - Street 1:727 BUCKSKIN AVE WEST
Practice Address - Street 2:
Practice Address - City:PILLAGER
Practice Address - State:MN
Practice Address - Zip Code:56473
Practice Address - Country:US
Practice Address - Phone:218-746-4555
Practice Address - Fax:218-746-4558
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND105181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice