Provider Demographics
NPI:1891027306
Name:ROBIRTS, GREG LEE (LD)
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:LEE
Last Name:ROBIRTS
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 SW BLACK BUTTE BLVD
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-2138
Mailing Address - Country:US
Mailing Address - Phone:541-548-5550
Mailing Address - Fax:
Practice Address - Street 1:639 SW BLACK BUTTE BLVD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2138
Practice Address - Country:US
Practice Address - Phone:541-548-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10120520122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist