Healthcare Provider Details

I. General information

NPI: 1962481358
Provider Name (Legal Business Name): DR. ROBERTSON DAVID LOAR
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

IV. Provider business mailing address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

V. Phone/Fax

Practice location:
  • Phone: 703-784-1853
  • Fax:
Mailing address:
  • Phone: 703-784-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1947
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: