Provider Demographics
NPI:1760664015
Name:CASEY A ROBERTS DDS PC
Entity Type:Organization
Organization Name:CASEY A ROBERTS DDS PC
Other - Org Name:MAGNOLIA CITY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-924-3330
Mailing Address - Street 1:2425 W. UNIVERSITY BLVD.
Mailing Address - Street 2:STE. 102
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701
Mailing Address - Country:US
Mailing Address - Phone:580-924-3330
Mailing Address - Fax:580-924-3339
Practice Address - Street 1:2425 W. UNIVERSITY BLVD.
Practice Address - Street 2:STE. 102
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701
Practice Address - Country:US
Practice Address - Phone:580-924-3330
Practice Address - Fax:580-924-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty