Provider Demographics
NPI:1558414359
Name:ROBERTS, RYAN (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 S MCCALL RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224-4512
Mailing Address - Country:US
Mailing Address - Phone:941-474-6466
Mailing Address - Fax:941-473-9351
Practice Address - Street 1:2121 S MCCALL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-4512
Practice Address - Country:US
Practice Address - Phone:941-474-6466
Practice Address - Fax:941-473-9351
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN164281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice