Provider Demographics
NPI:1659383412
Name:ROBERTSON, KEN (DMD)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 MARYLAND WAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5037
Mailing Address - Country:US
Mailing Address - Phone:615-371-8009
Mailing Address - Fax:615-661-4849
Practice Address - Street 1:5409 MARYLAND WAY
Practice Address - Street 2:SUITE 210
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5037
Practice Address - Country:US
Practice Address - Phone:615-371-8009
Practice Address - Fax:615-661-4849
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00045441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice