Provider Demographics
NPI:1962675397
Name:GINA W ROBERTS
Entity Type:Organization
Organization Name:GINA W ROBERTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:912-375-4531
Mailing Address - Street 1:PO BOX 1300
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-1300
Mailing Address - Country:US
Mailing Address - Phone:912-375-4531
Mailing Address - Fax:912-375-4532
Practice Address - Street 1:146 S TALLAHASSEE ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6457
Practice Address - Country:US
Practice Address - Phone:912-375-4531
Practice Address - Fax:912-375-4532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861601882OtherINDIVIDUAL NPI
GA00386636BMedicaid