Provider Demographics
NPI:1134269699
Name:ROBERTS, RENE WELCH (DMD)
Entity type:Individual
Prefix:DR
First Name:RENE
Middle Name:WELCH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 WARM SPRINGS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6858
Mailing Address - Country:US
Mailing Address - Phone:706-494-2679
Mailing Address - Fax:706-494-2697
Practice Address - Street 1:2751 WARM SPRINGS RD
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6858
Practice Address - Country:US
Practice Address - Phone:706-494-2679
Practice Address - Fax:706-494-2697
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011640122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2161791-UUOtherEMPLOYER STATE ID #
GA2161791-UUOtherEMPLOYER STATE ID #