Provider Demographics
NPI:1205265345
Name:ROBERTS, CORA (DHAT)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DHAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:HOONAH
Mailing Address - State:AK
Mailing Address - Zip Code:99829-0103
Mailing Address - Country:US
Mailing Address - Phone:907-945-3235
Mailing Address - Fax:
Practice Address - Street 1:201 3RD AVENUE, SUITE 115
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664
Practice Address - Country:US
Practice Address - Phone:907-224-4925
Practice Address - Fax:907-224-4933
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK13-114-DHAT125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1603850Medicaid