Provider Demographics
NPI:1770943011
Name:ROBERSON, MINDI J
Entity type:Individual
Prefix:
First Name:MINDI
Middle Name:J
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 HIGHWAY 618
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-4648
Mailing Address - Country:US
Mailing Address - Phone:318-439-2299
Mailing Address - Fax:
Practice Address - Street 1:1416 HAZEL ST
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:LA
Practice Address - Zip Code:71001-4114
Practice Address - Country:US
Practice Address - Phone:318-855-1426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6627122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist