Healthcare Provider Details

I. General information

NPI: 1750343802
Provider Name (Legal Business Name): MATTHEW ERIC ROBERTSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12611 E 21ST ST N
WICHITA KS
67206-3594
US

IV. Provider business mailing address

12611 E 21ST ST N
WICHITA KS
67206-3594
US

V. Phone/Fax

Practice location:
  • Phone: 316-742-1506
  • Fax:
Mailing address:
  • Phone: 316-742-1506
  • Fax: 316-742-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number21514
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number60512
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: