Provider Demographics
NPI:1619018462
Name:ROBERTSON, HOWARD LAMAR
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:LAMAR
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1697
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-1697
Mailing Address - Country:US
Mailing Address - Phone:662-614-5070
Mailing Address - Fax:
Practice Address - Street 1:60024 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MS
Practice Address - Zip Code:38870-9719
Practice Address - Country:US
Practice Address - Phone:662-651-7111
Practice Address - Fax:662-651-7115
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1912-80122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064850Medicaid