MEDICARE: COREY A. ROBERTSON, DDS A PROFESSIONAL DENTAL CORPORATION

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	4907	LA

General Provider Information

NPI Number	:	1821408683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COREY A. ROBERTSON, DDS A PROFESSIONAL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	3203 S SHERWOOD FOREST BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2220
Country	:	US
Telephone Number	:	225-201-0511
Fax Number	:

Provider Business Practice Location Address
First Line	:	3203 S SHERWOOD FOREST BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2220
Country	:	US
Telephone Number	:	225-201-0511
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CRYSTAL R PERRY
Credential	:
Telephone Number	:	252-520-3241

Provider Enumeration Date	:	05/02/2014
Last Update Date	:	05/02/2014

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