Provider Demographics
NPI:1750343802
Name:ROBERTSON, MATTHEW ERIC (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ERIC
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12611 E 21ST ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3594
Mailing Address - Country:US
Mailing Address - Phone:316-742-1506
Mailing Address - Fax:316-742-1507
Practice Address - Street 1:12611 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3594
Practice Address - Country:US
Practice Address - Phone:316-742-1506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215141223S0112X
KS605121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
12345OtherNONE