Provider Demographics
NPI:1588644199
Name:ROBERTS, JOHN M (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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 1:107 N MAIN
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67025
Mailing Address - Country:US
Mailing Address - Phone:316-540-3171
Mailing Address - Fax:316-542-9861
Practice Address - Street 1:107 N MAIN
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:KS
Practice Address - Zip Code:67025
Practice Address - Country:US
Practice Address - Phone:316-540-3171
Practice Address - Fax:316-542-9861
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS600841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice