Provider Demographics
NPI:1396812483
Name:ROBERTS, DANIEL J (DMD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-2831
Mailing Address - Country:US
Mailing Address - Phone:814-456-7821
Mailing Address - Fax:814-461-9522
Practice Address - Street 1:3419 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-2831
Practice Address - Country:US
Practice Address - Phone:814-456-7821
Practice Address - Fax:814-461-9522
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025375 L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice