Provider Demographics
NPI:1285799395
Name:ROBERTS, JOHN RANDALL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RANDALL
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 1:724 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-2015
Mailing Address - Country:US
Mailing Address - Phone:765-825-2051
Mailing Address - Fax:765-825-2091
Practice Address - Street 1:724 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2015
Practice Address - Country:US
Practice Address - Phone:765-825-2051
Practice Address - Fax:765-825-2091
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120081371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice