Provider Demographics
NPI:1578054557
Name:ROBERTS, WALLACE & ASSOCIATES PLLC
Entity Type:Organization
Organization Name:ROBERTS, WALLACE & ASSOCIATES PLLC
Other - Org Name:TRIAD KIDS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZWICKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-866-8811
Mailing Address - Street 1:2643 RANDLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-5153
Mailing Address - Country:US
Mailing Address - Phone:480-866-8811
Mailing Address - Fax:
Practice Address - Street 1:2643 RANDLEMAN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-5153
Practice Address - Country:US
Practice Address - Phone:336-544-2758
Practice Address - Fax:910-338-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1689746232Medicaid