MEDICARE: ROBERTS & LO 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	1223D0004X	Dental Anesthesiology

General Provider Information

NPI Number	:	1225505134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERTS & LO PLLC

Provider Business Mailing Address
First Line	:	5717 E THOMAS RD STE 100
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85251-7620
Country	:	US
Telephone Number	:
Fax Number	:

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

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	BRIDGET SHIELDS
Credential	:
Telephone Number	:	480-406-8677

Provider Enumeration Date	:	10/29/2018
Last Update Date	:	10/29/2018

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