Provider Demographics
NPI:1124245006
Name:ROBERTS, KENNETH WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-2000
Mailing Address - Country:US
Mailing Address - Phone:248-486-1730
Mailing Address - Fax:248-486-9544
Practice Address - Street 1:546 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-2000
Practice Address - Country:US
Practice Address - Phone:248-486-1730
Practice Address - Fax:248-486-9544
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010138711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice