Provider Demographics
NPI:1922112606
Name:ROBERTS, JAMES REID III (DMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:REID
Last Name:ROBERTS
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 COMMERCE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3575
Mailing Address - Country:US
Mailing Address - Phone:770-486-8516
Mailing Address - Fax:770-818-5547
Practice Address - Street 1:1125 COMMERCE DR STE 100
Practice Address - Street 2:SUITE A
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3575
Practice Address - Country:US
Practice Address - Phone:770-486-8516
Practice Address - Fax:770-818-5547
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA679226597BMedicaid
GA679226597CMedicaid
GA679226597AMedicaid