Provider Demographics
NPI:1952321945
Name:ROBERTS, IVAN BERYL (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:BERYL
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 1:353 OFFICE PLZ
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-2729
Mailing Address - Country:US
Mailing Address - Phone:850-877-5314
Mailing Address - Fax:850-877-8221
Practice Address - Street 1:353 OFFICE PLZ
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2729
Practice Address - Country:US
Practice Address - Phone:850-877-5314
Practice Address - Fax:850-877-8221
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL4009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist