Provider Demographics
NPI:1851327548
Name:DALE ROBERTS MD, DMD
Entity Type:Organization
Organization Name:DALE ROBERTS MD, DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DMD
Authorized Official - Phone:502-581-9223
Mailing Address - Street 1:201 ABRAHAM FLEXNER WAY
Mailing Address - Street 2:SUITE 1105
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3841
Mailing Address - Country:US
Mailing Address - Phone:502-581-9223
Mailing Address - Fax:502-581-9225
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY
Practice Address - Street 2:SUITE 1105
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3841
Practice Address - Country:US
Practice Address - Phone:502-581-9223
Practice Address - Fax:502-581-9225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22615208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6422615200Medicaid
KY6422615200Medicaid
KY00126Medicare PIN