Provider Demographics
NPI:1144234063
Name:JOHN G MCROBERTS DMD PA
Entity type:Organization
Organization Name:JOHN G MCROBERTS DMD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:HIX
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-654-5733
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633
Mailing Address - Country:US
Mailing Address - Phone:864-654-5733
Mailing Address - Fax:864-654-1117
Practice Address - Street 1:875 OLD CLEMSON HWY
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-8060
Practice Address - Country:US
Practice Address - Phone:864-654-5733
Practice Address - Fax:864-654-1117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN G MCROBERTS DMD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3718SC1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC122300000XOtherPROVIDER TAXONOMIES
SC1223G0001XOtherPROVIDER TAXONOMIES
SCZA9517Medicaid
SCZX1738Medicaid
SC3718OtherSC LIC #
SCZX3718Medicaid
SC1738OtherLIC# TN
SC4110OtherSC LIC #
SCZX1738Medicaid