MEDICARE: ROBERTS, WALLACE & ASSOCIATES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	9846	NC

General Provider Information

NPI Number	:	1104203579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERTS, WALLACE & ASSOCIATES PLLC

Provider Business Mailing Address
First Line	:	5069 UNIVERSITY PKWY
Second Line	:	11
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-6083
Country	:	US
Telephone Number	:	336-714-5726
Fax Number	:	336-792-4202

Provider Business Practice Location Address
First Line	:	5069 UNIVERSITY PKWY # 11
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-6083
Country	:	US
Telephone Number	:	336-714-5726
Fax Number	:	336-792-4202

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	TERESA ZWICKY
Credential	:
Telephone Number	:	480-866-8811

Provider Enumeration Date	:	05/05/2015
Last Update Date	:	08/15/2025

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