Provider Demographics
NPI:1922021435
Name:ROBERTS, MARK AUSTIN (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:AUSTIN
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 1:210 CRESTWAY ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-2135
Mailing Address - Country:US
Mailing Address - Phone:903-675-2122
Mailing Address - Fax:903-675-2154
Practice Address - Street 1:210 CRESTWAY ST
Practice Address - Street 2:SUITE 106
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-2135
Practice Address - Country:US
Practice Address - Phone:903-675-2122
Practice Address - Fax:903-675-2154
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice