Provider Demographics
NPI:1750491924
Name:ROBERTSON, KEVIN JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JON
Last Name:ROBERTSON
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 1:18771 E SHORELAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116
Mailing Address - Country:US
Mailing Address - Phone:440-331-9440
Mailing Address - Fax:
Practice Address - Street 1:10139 ROYALTON ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133
Practice Address - Country:US
Practice Address - Phone:440-230-2323
Practice Address - Fax:440-230-2229
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist