Provider Demographics
NPI:1790242550
Name:DR DANIEL ROBERTS PLLC
Entity Type:Organization
Organization Name:DR DANIEL ROBERTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-957-0303
Mailing Address - Street 1:2554 WOODMEADOW DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8033
Mailing Address - Country:US
Mailing Address - Phone:616-957-0303
Mailing Address - Fax:616-957-2732
Practice Address - Street 1:2554 WOODMEADOW DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8033
Practice Address - Country:US
Practice Address - Phone:616-957-0303
Practice Address - Fax:616-957-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental