Healthcare Provider Details

I. General information

NPI: 1861664989
Provider Name (Legal Business Name): EVA M ROBERTS DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 S. PATRICK DRIVE
PATRICK AIR FORCE BASE FL
32925-3607
US

IV. Provider business mailing address

1389 S. PATRICK DR.
PATRICK AIR FORCE BASE FL
32925-3607
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-6366
  • Fax: 321-494-2068
Mailing address:
  • Phone: 321-494-6366
  • Fax: 321-494-2068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH 10522
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: