=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255362612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANCE KELVIN ROBERTSON D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1170 N. MOAPA VALLEY BLVD. SUITE A
-----------------------------------------------------
City | OVERTON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-397-8844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 839
-----------------------------------------------------
City | OVERTON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89040-0839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-397-8844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2109
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------