Provider Demographics
NPI:1821420167
Name:ROBERTSON, DERRICK ALAN (IPDH)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:ALAN
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:IPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 FRANKLIN ST
Mailing Address - Street 2:PO BOX 1898
Mailing Address - City:BUCKSPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04416-4040
Mailing Address - Country:US
Mailing Address - Phone:207-469-2912
Mailing Address - Fax:207-469-6370
Practice Address - Street 1:166 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BUCKSPORT
Practice Address - State:ME
Practice Address - Zip Code:04416-4040
Practice Address - Country:US
Practice Address - Phone:207-469-2912
Practice Address - Fax:207-469-6370
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEIPH67124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist