Healthcare Provider Details

I. General information

NPI: 1164588802
Provider Name (Legal Business Name): JEFFERY A ROBERTS D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 S EMERSON AVE STE. 200
INDIANAPOLIS IN
46237-2600
US

IV. Provider business mailing address

5955 S EMERSON AVE STE. 200
INDIANAPOLIS IN
46237-2600
US

V. Phone/Fax

Practice location:
  • Phone: 317-536-1365
  • Fax: 317-536-1367
Mailing address:
  • Phone: 317-536-1365
  • Fax: 317-536-1367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12010722A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: