Healthcare Provider Details

I. General information

NPI: 1285799395
Provider Name (Legal Business Name): JOHN RANDALL ROBERTS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 N GRAND AVE
CONNERSVILLE IN
47331-2015
US

IV. Provider business mailing address

724 N GRAND AVE
CONNERSVILLE IN
47331-2015
US

V. Phone/Fax

Practice location:
  • Phone: 765-825-2051
  • Fax: 765-825-2091
Mailing address:
  • Phone: 765-825-2051
  • Fax: 765-825-2091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12008137
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: