1700890480 NPI number — DR. STEPHEN WAYNE ROBERTSON D.M.D.,

Table of content: DR. STEPHEN WAYNE ROBERTSON D.M.D., (NPI 1700890480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700890480 NPI number — DR. STEPHEN WAYNE ROBERTSON D.M.D.,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
STEPHEN
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.,
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBERTSON
Provider Other First Name:
DAVIS
Provider Other Middle Name:
AND
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.M.D., P.S.C.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1700890480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 DESTINY LN
Provider Second Line Business Mailing Address:
1720 DESTINY LANE
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42104-1063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-842-3554
Provider Business Mailing Address Fax Number:
270-781-4644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 DESTINY LN
Provider Second Line Business Practice Location Address:
1720 DESTINY LANE
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42104-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-842-3554
Provider Business Practice Location Address Fax Number:
270-781-4644
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2708 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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