MEDICARE: MICHAEL AUSTIN ROBERTSON

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	122300000X	Dentist	23852	TX
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	23852	TX

General Provider Information

NPI Number	:	1952672610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL AUSTIN ROBERTSON

Provider Business Mailing Address
First Line	:	2730 COUNTRY CLUB RD STE A
Second Line	:
City	:	LUCAS
State	:	TX
Zip	:	75002-8781
Country	:	US
Telephone Number	:	972-363-8020
Fax Number	:	972-363-8024

Provider Business Practice Location Address
First Line	:	2730 COUNTRY CLUB RD STE A
Second Line	:
City	:	LUCAS
State	:	TX
Zip	:	75002-8781
Country	:	US
Telephone Number	:	972-363-8020
Fax Number	:	972-363-8024

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

Provider Enumeration Date	:	01/25/2012
Last Update Date	:	05/22/2019

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