Provider Demographics
NPI:1124058961
Name:ROBERTS, STANLEY ALAN (DMP)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:ALAN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ROCK WOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-4531
Mailing Address - Country:US
Mailing Address - Phone:781-231-2483
Mailing Address - Fax:781-231-2485
Practice Address - Street 1:10 KIRTLAND ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01905-1821
Practice Address - Country:US
Practice Address - Phone:781-595-2552
Practice Address - Fax:781-593-0730
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0252115Medicaid