MEDICARE: JESSICA LORRAINE ROBERTSON DMD

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	1223P0221X	Pediatric Dentistry	D6814	AZ

General Provider Information

NPI Number	:	1316041437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LORRAINE ROBERTSON DMD

Provider Business Mailing Address
First Line	:	1773 W SEQUOIA DRIVE
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001
Country	:	US
Telephone Number	:	928-213-5559
Fax Number	:

Provider Business Practice Location Address
First Line	:	1024 N SAN FRANCISCO
Second Line	:	SUITE 101
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001
Country	:	US
Telephone Number	:	928-779-0385
Fax Number	:	928-779-6487

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

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	07/08/2007

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