Provider Demographics
NPI:1891427894
Name:ROBERTSON, KATELYN RIDLEY (DDS)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:RIDLEY
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3290 HIGHWAY 423
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-8450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 RB WILSON DR
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-1726
Practice Address - Country:US
Practice Address - Phone:731-986-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11931122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist