Provider Demographics
NPI:1326419383
Name:ROBERTS, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BEACON ST
Mailing Address - Street 2:APARTMENT #1
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-2703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 NE 5TH AVE
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862-1704
Practice Address - Country:US
Practice Address - Phone:541-809-7043
Practice Address - Fax:541-516-4046
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD112951223G0001X
PADS0406451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice