Provider Demographics
NPI:1013086248
Name:ROBERTS FAMILY DENTAL, PC
Entity Type:Organization
Organization Name:ROBERTS FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RESA
Authorized Official - Middle Name:JOHNELLE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-556-1393
Mailing Address - Street 1:PO BOX 370777
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-0777
Mailing Address - Country:US
Mailing Address - Phone:404-243-0217
Mailing Address - Fax:678-904-4944
Practice Address - Street 1:3660 FLAT SHOALS ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1632
Practice Address - Country:US
Practice Address - Phone:404-243-0217
Practice Address - Fax:404-243-9313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010168122300000X
GADN012459122300000X
GADN013502122300000X
GADN0567181223S0112X
GADH007395124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA559391OtherUCCI - ROBERTS