Provider Demographics
NPI:1548761711
Name:ROBERSON FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:ROBERSON FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:WILLIS
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-452-5122
Mailing Address - Street 1:2001 CAWOOD FALLS LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37931-4065
Mailing Address - Country:US
Mailing Address - Phone:504-452-5122
Mailing Address - Fax:
Practice Address - Street 1:1740 BIG SPRINGS RD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-8206
Practice Address - Country:US
Practice Address - Phone:865-681-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8949261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental