Provider Demographics
NPI:1720200892
Name:ROBERTS, DALE LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:LEE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:DALE
Other - Middle Name:LEE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1211 S DOUGLAS HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4949
Mailing Address - Country:US
Mailing Address - Phone:307-682-6771
Mailing Address - Fax:307-682-9895
Practice Address - Street 1:1211 S DOUGLAS HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4949
Practice Address - Country:US
Practice Address - Phone:307-682-6771
Practice Address - Fax:307-682-9895
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist