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General NPI Number Information
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NPI Number | 1306454178
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Entity Type | Organization
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Legal Business Name | SUSAN ROBERTS PEDIATRIC DENTISTRY PLLC
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Dates
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Enumeration Date | 07/17/2020
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Last Update Date | 07/17/2020
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Provider Practice Location Address
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Address Line | 5411 BASSWOOD BLVD STE 201
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City | FORT WORTH
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State | TX
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Zip | 76137-4479
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Country | US
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Telephone | 817-656-3999
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Fax |
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Provider Business Mailing Address
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Address Line | 3575 LONE STAR CIR STE 310
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City | FORT WORTH
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State | TX
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Zip | 76177-8908
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Country | US
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Telephone | 817-350-6500
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JEREMY LUSTIG
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Credential | DDS
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Telephone | 214-335-0862
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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