Provider Demographics
NPI:1821378084
Name:ROBERTS, EVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WILFORD HALL AMBULATORY SURGICAL CENTER
Mailing Address - Street 2:1100 WILFORD HALL LOOP
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:210-539-7036
Mailing Address - Fax:
Practice Address - Street 1:WILFORD HALL AMBULATORY SURGICAL CENTER
Practice Address - Street 2:1100 WILFORD HALL LOOP
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-539-7036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27079122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist