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General NPI Number Information
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NPI Number | 1760621106
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Entity Type | Organization
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Legal Business Name | ROBERTS DENTAL RANCH OF TEXAS, PA
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Dates
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Enumeration Date | 02/09/2009
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Last Update Date | 02/09/2009
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Provider Practice Location Address
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Address Line | 2440 EAST PROSPER TRAIL
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City | PROSPER
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State | TX
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Zip | 75078
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Country | US
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Telephone | 972-347-6444
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Fax |
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Provider Business Mailing Address
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Address Line | 1921 STILLHOUSE HOLLOW DR
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City | PROSPER
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State | TX
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Zip | 75078-7203
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Country | US
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Telephone | 972-347-6444
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Fax |
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Authorized Official
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Title or Position | CO-DIRECTOR
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Name | DR. RAENIE OAKES ROBERTS
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Credential | DDS
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Telephone | 214-728-9419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 21466
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 22822
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License Number State | TX
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