MEDICARE: OHIO KIDS DENTAL TOLEDO - ROBERTS DMD, LLC

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

General Provider Information

NPI Number	:	1538909742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OHIO KIDS DENTAL TOLEDO - ROBERTS DMD, LLC

Provider Business Mailing Address
First Line	:	731 CONANT ST
Second Line	:
City	:	MAUMEE
State	:	OH
Zip	:	43537-2899
Country	:	US
Telephone Number	:	480-866-8811
Fax Number	:

Provider Business Practice Location Address
First Line	:	731 CONANT ST
Second Line	:
City	:	MAUMEE
State	:	OH
Zip	:	43537-2899
Country	:	US
Telephone Number	:	480-866-8811
Fax Number	:

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

Provider Enumeration Date	:	05/28/2024
Last Update Date	:	05/28/2024

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