Provider Demographics
NPI:1366543779
Name:ROBERTS, RONALD GLENN (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:GLENN
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 249
Mailing Address - Street 2:409 CHURCH AVENUE
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72740
Mailing Address - Country:US
Mailing Address - Phone:479-738-2777
Mailing Address - Fax:479-738-2705
Practice Address - Street 1:409 CHURCH AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72740
Practice Address - Country:US
Practice Address - Phone:479-738-2777
Practice Address - Fax:479-738-2705
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR19431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice