Provider Demographics
NPI:1760746747
Name:ROBERTS, MICAH A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4517 N ROCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3841
Mailing Address - Country:US
Mailing Address - Phone:309-688-0121
Mailing Address - Fax:309-688-5643
Practice Address - Street 1:4517 N ROCKWOOD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3841
Practice Address - Country:US
Practice Address - Phone:309-693-0043
Practice Address - Fax:309-688-5643
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029023122300000X
IL0190290231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist