Provider Demographics
NPI:1801962196
Name:CHARLES W ROBERTS IV DDS & KARI L LUNDBERG DDS PA
Entity type:Organization
Organization Name:CHARLES W ROBERTS IV DDS & KARI L LUNDBERG DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WAITSEL
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-664-5437
Mailing Address - Street 1:142 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 100 & 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-663-1234
Mailing Address - Fax:704-663-7912
Practice Address - Street 1:142 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 100 & 200
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-663-1234
Practice Address - Fax:704-663-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7002122300000X
NC7023122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902375Medicaid
NC902E8OtherHEALTH CHOICE