Provider Demographics
NPI:1518083948
Name:ROBERTS, ROBERT THEODORE
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:THEODORE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 FRIARS POINT RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-9111
Mailing Address - Country:US
Mailing Address - Phone:662-624-6862
Mailing Address - Fax:662-624-5985
Practice Address - Street 1:632 FRIARS POINT RD
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-9111
Practice Address - Country:US
Practice Address - Phone:662-624-6862
Practice Address - Fax:662-624-5985
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1470711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00062287Medicaid