Provider Demographics
NPI:1568657591
Name:ROBERSON, MARTIN W (DDS)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:W
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 SIMMONS RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-1943
Mailing Address - Country:US
Mailing Address - Phone:865-675-3009
Mailing Address - Fax:865-675-3028
Practice Address - Street 1:310 SIMMONS RD
Practice Address - Street 2:STE. I
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-1943
Practice Address - Country:US
Practice Address - Phone:865-675-3009
Practice Address - Fax:865-675-3028
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3575122300000X
TN8949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000OtherUPIN