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NPI Code Detail

MEDICARE: DR. JACK ROBERTS DDS

MEDICARE: DR. JACK ROBERTS DDS
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
1122300000XDentist09944TX

General Provider Information

NPI Number : 1932311164
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JACK ROBERTS DDS
Provider Business Mailing Address
First Line : 4409 PACK SADDLE PASS
Second Line :
City : AUSTIN
State : TX
Zip : 78745-1623
Country : US
Telephone Number : 512-444-1871
Fax Number :
Provider Business Practice Location Address
First Line : 4409 PACK SADDLE PASS
Second Line :
City : AUSTIN
State : TX
Zip : 78745-1623
Country : US
Telephone Number : 512-444-1871
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2007
Last Update Date : 07/08/2007

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