Healthcare Provider Details

I. General information

NPI: 1932488210
Provider Name (Legal Business Name): ASHLEY THEODORE ROBERTS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 SAINT ROSE PKWY UNIT 777112
HENDERSON NV
89077-8805
US

IV. Provider business mailing address

3055 SAINT ROSE PKWY UNIT 777112
HENDERSON NV
89077-8805
US

V. Phone/Fax

Practice location:
  • Phone: 702-553-6762
  • Fax: 855-655-4767
Mailing address:
  • Phone: 702-553-6762
  • Fax: 855-655-4767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberD009435
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number6171
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: