Provider Demographics
NPI:1497354450
Name:ROBERTS, CHANELLE (DDS)
Entity Type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 HALF ST SE APT 817
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-4581
Mailing Address - Country:US
Mailing Address - Phone:757-300-8342
Mailing Address - Fax:
Practice Address - Street 1:2737 DEVONSHIRE PL NW STE A
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-3479
Practice Address - Country:US
Practice Address - Phone:202-232-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN1002161122300000X
MD17170122300000X
VA0401417083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist