Healthcare Provider Details

I. General information

NPI: 1215961867
Provider Name (Legal Business Name): MARGARET GRILLS ROBERTS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF SIDNEY AND LAMONT (JOHNSON CITY) JAMES H. QUILLEN/VAMC
MOUNTAIN HOME TN
37684
US

IV. Provider business mailing address

1305 W LAKEVIEW DR
JOHNSON CITY TN
37601-3217
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-1171
  • Fax: 423-979-3428
Mailing address:
  • Phone: 412-926-1171
  • Fax: 423-979-3428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number823
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: