Provider Demographics
NPI:1588072045
Name:ROBERTS, JADA
Entity type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 N WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2510
Mailing Address - Country:US
Mailing Address - Phone:765-673-0633
Mailing Address - Fax:
Practice Address - Street 1:1102 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2510
Practice Address - Country:US
Practice Address - Phone:765-673-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012082A122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist