Provider Demographics
NPI:1942565270
Name:ROBERTSON, JARED (DDS)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:
Last Name:ROBERTSON
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 1:10000 COORS BYP NW
Mailing Address - Street 2:SUITE G218
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4040
Mailing Address - Country:US
Mailing Address - Phone:505-242-4867
Mailing Address - Fax:505-890-2883
Practice Address - Street 1:10000 COORS BYP NW
Practice Address - Street 2:SUITE G218
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4040
Practice Address - Country:US
Practice Address - Phone:505-242-4867
Practice Address - Fax:505-890-2883
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD36991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDD3699OtherSTATE DENTAL LISENCE