Healthcare Provider Details

I. General information

NPI: 1255362612
Provider Name (Legal Business Name): LANCE KELVIN ROBERTSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 N. MOAPA VALLEY BLVD. SUITE A
OVERTON NV
89040
US

IV. Provider business mailing address

PO BOX 839
OVERTON NV
89040-0839
US

V. Phone/Fax

Practice location:
  • Phone: 702-397-8844
  • Fax:
Mailing address:
  • Phone: 702-397-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2109
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: