Provider Demographics
NPI:1417176595
Name:ROBERTS, AMY DEANN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:DEANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 E KINGSBURY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-2033
Mailing Address - Country:US
Mailing Address - Phone:417-823-0546
Mailing Address - Fax:
Practice Address - Street 1:601 N 21ST ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9184
Practice Address - Country:US
Practice Address - Phone:417-582-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003012124124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist