Provider Demographics
NPI:1508566985
Name:ROBERTS, STACY (RDH)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
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 1:353 41ST ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9193
Mailing Address - Country:US
Mailing Address - Phone:269-214-2779
Mailing Address - Fax:
Practice Address - Street 1:1535 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-8197
Practice Address - Country:US
Practice Address - Phone:269-673-3619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902017012124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist