Provider Demographics
NPI:1790843241
Name:ROBERTS, JONATHAN MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 25TH STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-3214
Mailing Address - Country:US
Mailing Address - Phone:812-379-9561
Mailing Address - Fax:812-372-8157
Practice Address - Street 1:2121 25TH STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3214
Practice Address - Country:US
Practice Address - Phone:812-379-9561
Practice Address - Fax:812-372-8157
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist