Provider Demographics
NPI:1518103787
Name:RONALD G. ROBERTS, D.D.S.
Entity Type:Organization
Organization Name:RONALD G. ROBERTS, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-738-2777
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:409 CHURCH AVENUE
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72740-0249
Mailing Address - Country:US
Mailing Address - Phone:479-738-2777
Mailing Address - Fax:479-738-2705
Practice Address - Street 1:409 CHURCH AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72740-0249
Practice Address - Country:US
Practice Address - Phone:479-738-2777
Practice Address - Fax:479-738-2705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366543779OtherNPI # PERSONAL
AR162357608Medicaid