Provider Demographics
NPI:1699742395
Name:ROBERTS, DENTON R (MD)
Entity type:Individual
Prefix:
First Name:DENTON
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DENTON
Other - Middle Name:R
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13923 W. WAINWRIGHT DR.
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1969
Mailing Address - Country:US
Mailing Address - Phone:208-938-5624
Mailing Address - Fax:208-938-5764
Practice Address - Street 1:13923 W WAINWRIGHT DR
Practice Address - Street 2:SUITE 301
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1969
Practice Address - Country:US
Practice Address - Phone:208-938-5624
Practice Address - Fax:208-938-5764
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10066207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H90320Medicare UPIN
1100341Medicare PIN