Healthcare Provider Details

I. General information

NPI: 1538148085
Provider Name (Legal Business Name): BRIAN MARK ROBERTS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 DUNHAM ST
MONTE VISTA CO
81144-0403
US

IV. Provider business mailing address

PO BOX 529
MONTE VISTA CO
81144-0529
US

V. Phone/Fax

Practice location:
  • Phone: 719-852-5432
  • Fax:
Mailing address:
  • Phone: 719-852-5432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number104946
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: