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General NPI Number Information
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NPI Number | 1700890480
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Entity Type | Individual
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Provider Name | STEPHEN WAYNE ROBERTSON D.M.D.,
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Gender | Male
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Dates
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Enumeration Date | 07/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1720 DESTINY LN 1720 DESTINY LANE
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City | BOWLING GREEN
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State | KY
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Zip | 42104-1063
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Country | US
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Telephone | 270-842-3554
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Fax | 270-781-4644
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Provider Business Mailing Address
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Address Line | 1720 DESTINY LN 1720 DESTINY LANE
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City | BOWLING GREEN
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State | KY
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Zip | 42104-1063
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Country | US
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Telephone | 270-842-3554
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Fax | 270-781-4644
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2708
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License Number State | KY
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