Provider Demographics
NPI:1861910036
Name:J. SHANE ROBERTS FAMILY DENTISTRY
Entity type:Organization
Organization Name:J. SHANE ROBERTS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-744-4258
Mailing Address - Street 1:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:AL
Mailing Address - Zip Code:35127-0445
Mailing Address - Country:US
Mailing Address - Phone:205-744-4258
Mailing Address - Fax:205-744-4255
Practice Address - Street 1:904 4TH ST
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:AL
Practice Address - Zip Code:35127-1059
Practice Address - Country:US
Practice Address - Phone:205-744-4258
Practice Address - Fax:205-744-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4013261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherGENERAL DENTIST