Provider Demographics
NPI:1679570188
Name:ROBERTSON, EDWARD N (DMD,MS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:N
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 WABANAKI WAY
Mailing Address - Street 2:PENOBSCOT NATION HEALTH DEPARTMENT
Mailing Address - City:INDIAN ISLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04468-1252
Mailing Address - Country:US
Mailing Address - Phone:207-817-7418
Mailing Address - Fax:207-817-7453
Practice Address - Street 1:23 WABANAKI WAY
Practice Address - Street 2:PENOBSCOT NATION HEALTH DEPARTMENT
Practice Address - City:INDIAN ISLAND
Practice Address - State:ME
Practice Address - Zip Code:04468-1252
Practice Address - Country:US
Practice Address - Phone:207-817-7418
Practice Address - Fax:207-817-7453
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist