MEDICARE: DR. MARY ELIZABETH ROBERTS D.D.S.

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	122300000X	Dentist	22DI01537400	NJ
2	122300000X	Dentist	0401006046	VA
3	122300000X	Dentist	2742-15	WI

General Provider Information

NPI Number	:	1245779479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ELIZABETH ROBERTS D.D.S.

Provider Business Mailing Address
First Line	:	8 LAUREL HILL DR
Second Line	:
City	:	RANDOLPH
State	:	NJ
Zip	:	07869-4627
Country	:	US
Telephone Number	:	973-895-5476
Fax Number	:

Provider Business Practice Location Address
First Line	:	8 LAUREL HILL DR
Second Line	:
City	:	RANDOLPH
State	:	NJ
Zip	:	07869-4627
Country	:	US
Telephone Number	:	973-895-5476
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2017
Last Update Date	:	02/21/2017

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