Healthcare Provider Details

I. General information

NPI: 1760621106
Provider Name (Legal Business Name): ROBERTS DENTAL RANCH OF TEXAS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 EAST PROSPER TRAIL
PROSPER TX
75078
US

IV. Provider business mailing address

1921 STILLHOUSE HOLLOW DR
PROSPER TX
75078-7203
US

V. Phone/Fax

Practice location:
  • Phone: 972-347-6444
  • Fax:
Mailing address:
  • Phone: 972-347-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22822
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number21466
License Number StateTX

VIII. Authorized Official

Name: DR. RAENIE OAKES ROBERTS
Title or Position: CO-DIRECTOR
Credential: DDS
Phone: 214-728-9419