Provider Demographics
NPI:1891319794
Name:ROBERTS, TERRENCE (DDS)
Entity type:Individual
Prefix:
First Name:TERRENCE
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 1:996 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47320-1519
Mailing Address - Country:US
Mailing Address - Phone:765-789-9048
Mailing Address - Fax:765-789-9063
Practice Address - Street 1:996 W STATE ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47320-1519
Practice Address - Country:US
Practice Address - Phone:765-789-9048
Practice Address - Fax:765-789-9063
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013359122300000X
IN12013359A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist