Provider Demographics
NPI:1801182803
Name:ROBERTS, SCOTT CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHRISTOPHER
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 FOREST SQ STE F
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-4400
Mailing Address - Country:US
Mailing Address - Phone:903-758-3722
Mailing Address - Fax:
Practice Address - Street 1:444 FOREST SQ STE F
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4400
Practice Address - Country:US
Practice Address - Phone:903-758-3722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX270151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice