Provider Demographics
NPI:1871777136
Name:DR. TONY ROBERTS D.D.S. LLC
Entity type:Organization
Organization Name:DR. TONY ROBERTS D.D.S. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-542-6014
Mailing Address - Street 1:5623 TERRACINA PL
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-5582
Mailing Address - Country:US
Mailing Address - Phone:719-542-6014
Mailing Address - Fax:719-583-7937
Practice Address - Street 1:517 W 5TH ST
Practice Address - Street 2:STE 106
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3185
Practice Address - Country:US
Practice Address - Phone:719-542-6014
Practice Address - Fax:719-583-7937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1052021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02052025Medicaid
CO46201751Medicaid