Provider Demographics
NPI:1437302551
Name:RICHARD C. ROBERTSON DDS PLC
Entity Type:Organization
Organization Name:RICHARD C. ROBERTSON DDS PLC
Other - Org Name:CALEDONIA DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-891-8141
Mailing Address - Street 1:9090 S RODGERS CT SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-8052
Mailing Address - Country:US
Mailing Address - Phone:616-891-8141
Mailing Address - Fax:616-891-8142
Practice Address - Street 1:9090 S RODGERS CT SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8052
Practice Address - Country:US
Practice Address - Phone:616-891-8141
Practice Address - Fax:616-891-8142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI13197122300000X
MI19398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty