Provider Demographics
NPI:1750594412
Name:ROBERTSON, JAMES MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:J
Other - Middle Name:MICHAEL
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:103 PARKGATE DRIVE EXTENDED
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-3038
Mailing Address - Country:US
Mailing Address - Phone:662-842-2448
Mailing Address - Fax:662-842-8374
Practice Address - Street 1:103 PARKGATE DRIVE EXTENDED
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3038
Practice Address - Country:US
Practice Address - Phone:662-842-2448
Practice Address - Fax:662-842-8374
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2571901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics