Healthcare Provider Details

I. General information

NPI: 1043748411
Provider Name (Legal Business Name): ANNIE ROBERTS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 N BROADWAY ST
LA CYGNE KS
66040-4205
US

IV. Provider business mailing address

211 E PARK ST
PLEASANTON KS
66075-4065
US

V. Phone/Fax

Practice location:
  • Phone: 913-757-4429
  • Fax:
Mailing address:
  • Phone: 913-235-1141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61400
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: