Provider Demographics
NPI:1356444293
Name:ROBERTS, GERALD M JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:M
Last Name:ROBERTS
Suffix:JR
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 1:4058 FLYING C RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-9662
Mailing Address - Country:US
Mailing Address - Phone:530-677-0272
Mailing Address - Fax:
Practice Address - Street 1:4058 FLYING C RD
Practice Address - Street 2:SUITE 9
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-9662
Practice Address - Country:US
Practice Address - Phone:530-677-0272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA372801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice