Healthcare Provider Details

I. General information

NPI: 1679570188
Provider Name (Legal Business Name): EDWARD N. ROBERTSON DMD,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 WABANAKI WAY PENOBSCOT NATION HEALTH DEPARTMENT
INDIAN ISLAND ME
04468-1252
US

IV. Provider business mailing address

23 WABANAKI WAY PENOBSCOT NATION HEALTH DEPARTMENT
INDIAN ISLAND ME
04468-1252
US

V. Phone/Fax

Practice location:
  • Phone: 207-817-7418
  • Fax: 207-817-7453
Mailing address:
  • Phone: 207-817-7418
  • Fax: 207-817-7453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number17465
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: