Provider Demographics
NPI:1518647601
Name:ROBERTS, ANTONIO DEMEKTRICK (DDS, MHS)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:DEMEKTRICK
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DDS, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 BRIARCLIFF DR APT X
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5297
Mailing Address - Country:US
Mailing Address - Phone:318-664-1080
Mailing Address - Fax:
Practice Address - Street 1:520 HIGHWAY 76
Practice Address - Street 2:SUITE 9
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188
Practice Address - Country:US
Practice Address - Phone:615-672-7221
Practice Address - Fax:615-672-7211
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13385122300000X
TN127411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist