Provider Demographics
NPI:1871083634
Name:ROBERTS, DONALD CLYDE (DDS)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:CLYDE
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 1:299W-670S
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:IN
Mailing Address - Zip Code:46341-8833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:299W-670S
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:IN
Practice Address - Zip Code:46341-8833
Practice Address - Country:US
Practice Address - Phone:212-996-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006225A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist