Provider Demographics
NPI:1578263711
Name:ROBERTS, DYLAN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:D
Last Name:ROBERTS
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 1:620 LAMAR CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:LA
Mailing Address - Zip Code:71232-7299
Mailing Address - Country:US
Mailing Address - Phone:318-439-4512
Mailing Address - Fax:
Practice Address - Street 1:307 CHISUM ST
Practice Address - Street 2:
Practice Address - City:SICILY ISLAND
Practice Address - State:LA
Practice Address - Zip Code:71368-4807
Practice Address - Country:US
Practice Address - Phone:318-389-5727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA7442122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program