=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316170210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLOTTE ROBERSON DDS., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2009
-----------------------------------------------------
Last Update Date | 08/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11239 TAMPA AVE SUITE 208
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91326-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-368-6277
-----------------------------------------------------
Fax | 818-366-2491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11239 TAMPA AVE SUITE 208
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91326-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-368-6277
-----------------------------------------------------
Fax | 818-366-2491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLOTTE ELIZABETH ROBERSON
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 818-368-6266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 29997
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------