Provider Demographics
NPI:1861905010
Name:ROBERTSON, CLIFF P (LD)
Entity type:Individual
Prefix:
First Name:CLIFF
Middle Name:P
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2112
Mailing Address - Country:US
Mailing Address - Phone:541-889-3750
Mailing Address - Fax:
Practice Address - Street 1:975 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2112
Practice Address - Country:US
Practice Address - Phone:541-889-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10170823122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist