Provider Demographics
NPI:1326592312
Name:KENNETH W ROBERTS, DDS, PC
Entity Type:Organization
Organization Name:KENNETH W ROBERTS, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-486-1730
Mailing Address - Street 1:546 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-2000
Mailing Address - Country:US
Mailing Address - Phone:248-486-1730
Mailing Address - Fax:
Practice Address - Street 1:546 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-2000
Practice Address - Country:US
Practice Address - Phone:248-486-1730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI013871122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty