MEDICARE: DR. SUSAN MERLENE ROBERTS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	15587	TX

General Provider Information

NPI Number	:	1114023736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN MERLENE ROBERTS DDS

Provider Business Mailing Address
First Line	:	6650 N BEACH
Second Line	:	#118
City	:	FT WORTH
State	:	TX
Zip	:	76137
Country	:	US
Telephone Number	:	817-656-3999
Fax Number	:	817-656-7862

Provider Business Practice Location Address
First Line	:	6650 N BEACH
Second Line	:	#118
City	:	FT WORTH
State	:	TX
Zip	:	76137
Country	:	US
Telephone Number	:	817-656-3999
Fax Number	:	817-656-7862

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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