Healthcare Provider Details

I. General information

NPI: 1154319176
Provider Name (Legal Business Name): R. SCOTT ROBERTS DDS PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CEDAR ST
NORTH BEND OR
97459-1108
US

IV. Provider business mailing address

3500 CEDAR ST
NORTH BEND OR
97459-1108
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-0558
  • Fax: 541-756-1974
Mailing address:
  • Phone: 541-756-0558
  • Fax: 541-756-1974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD7517
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: