Provider Demographics
NPI:1538148085
Name:ROBERTS, BRIAN MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MARK
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:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:MONTE VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81144-0529
Mailing Address - Country:US
Mailing Address - Phone:719-852-5432
Mailing Address - Fax:
Practice Address - Street 1:403 DUNHAM ST
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-0403
Practice Address - Country:US
Practice Address - Phone:719-852-5432
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104946122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist