Provider Demographics
NPI:1952783722
Name:DR JON M. ROBERTS FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:DR JON M. ROBERTS FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-379-9561
Mailing Address - Street 1:2320 NORTHPARK SUITE C.
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-4482
Mailing Address - Country:US
Mailing Address - Phone:812-379-9561
Mailing Address - Fax:812-372-8157
Practice Address - Street 1:2320 NORTHPARK SUITE C.
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4482
Practice Address - Country:US
Practice Address - Phone:812-379-9561
Practice Address - Fax:812-372-8157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100052120AMedicaid