Provider Demographics
NPI:1790191492
Name:SUSAN ROBERTS, DDS, MS
Entity Type:Organization
Organization Name:SUSAN ROBERTS, DDS, MS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:817-656-3999
Mailing Address - Street 1:5411 BASSWOOD BLVD
Mailing Address - Street 2:SUITE #201
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137
Mailing Address - Country:US
Mailing Address - Phone:817-656-3999
Mailing Address - Fax:817-656-7862
Practice Address - Street 1:5411 BASSWOOD BLVD
Practice Address - Street 2:SUITE #201
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137
Practice Address - Country:US
Practice Address - Phone:817-656-3999
Practice Address - Fax:817-656-7862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1558701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty