Provider Demographics
NPI:1538255799
Name:ROBERTSON, GREG A (DDS)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:A
Last Name:ROBERTSON
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 1:1201 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-4838
Mailing Address - Country:US
Mailing Address - Phone:318-473-9005
Mailing Address - Fax:318-442-9865
Practice Address - Street 1:1201 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-4838
Practice Address - Country:US
Practice Address - Phone:318-473-9005
Practice Address - Fax:318-442-9865
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA44451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice