=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851327548
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALE ROBERTS MD, DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 10/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 ABRAHAM FLEXNER WAY SUITE 1105
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-581-9223
-----------------------------------------------------
Fax | 502-581-9225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 ABRAHAM FLEXNER WAY SUITE 1105
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-581-9223
-----------------------------------------------------
Fax | 502-581-9225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DALE ROBERTS
-----------------------------------------------------
Credential | MD, DMD
-----------------------------------------------------
Telephone | 502-581-9223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 22615
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------