Provider Demographics
NPI:1700890480
Name:ROBERTSON, STEPHEN WAYNE (DMD,)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WAYNE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DMD,
Other - Prefix:DR
Other - First Name:DAVIS
Other - Middle Name:AND
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD, PSC
Mailing Address - Street 1:1720 DESTINY LN
Mailing Address - Street 2:1720 DESTINY LANE
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-1063
Mailing Address - Country:US
Mailing Address - Phone:270-842-3554
Mailing Address - Fax:270-781-4644
Practice Address - Street 1:1720 DESTINY LN
Practice Address - Street 2:1720 DESTINY LANE
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1063
Practice Address - Country:US
Practice Address - Phone:270-842-3554
Practice Address - Fax:270-781-4644
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice