Provider Demographics
NPI:1972832137
Name:ROBERTSON, GEORGE OKEY
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:OKEY
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2902
Mailing Address - Country:US
Mailing Address - Phone:573-218-7100
Mailing Address - Fax:573-750-5818
Practice Address - Street 1:1012 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2902
Practice Address - Country:US
Practice Address - Phone:573-218-7100
Practice Address - Fax:573-750-5818
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0114841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice