Healthcare Provider Details

I. General information

NPI: 1467555086
Provider Name (Legal Business Name): RANDY M ROBERTSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 N AVE C
ELGIN TX
78621
US

IV. Provider business mailing address

PO BOX 897
ELGIN TX
78621
US

V. Phone/Fax

Practice location:
  • Phone: 512-281-4260
  • Fax: 512-285-3229
Mailing address:
  • Phone: 512-281-4260
  • Fax: 512-285-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13503
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: