Provider Demographics
NPI:1578133666
Name:ROBERTS, CALLAN (DMD)
Entity Type:Individual
Prefix:
First Name:CALLAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 W BROADWAY UNIT 416
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1058
Mailing Address - Country:US
Mailing Address - Phone:586-719-2314
Mailing Address - Fax:
Practice Address - Street 1:225 CENTRE ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5524
Practice Address - Country:US
Practice Address - Phone:781-300-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist