Provider Demographics
NPI:1760621106
Name:ROBERTS DENTAL RANCH OF TEXAS, PA
Entity Type:Organization
Organization Name:ROBERTS DENTAL RANCH OF TEXAS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAENIE
Authorized Official - Middle Name:OAKES
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-728-9419
Mailing Address - Street 1:1921 STILLHOUSE HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-7203
Mailing Address - Country:US
Mailing Address - Phone:972-347-6444
Mailing Address - Fax:
Practice Address - Street 1:2440 EAST PROSPER TRAIL
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078
Practice Address - Country:US
Practice Address - Phone:972-347-6444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228221223P0221X
TX214661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty