Provider Demographics
NPI:1053596429
Name:DR. GREG A. ROBERTS P.C.
Entity type:Organization
Organization Name:DR. GREG A. ROBERTS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-479-9070
Mailing Address - Street 1:5742 S 1475 E STE 100
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4857
Mailing Address - Country:US
Mailing Address - Phone:801-479-9070
Mailing Address - Fax:801-479-9078
Practice Address - Street 1:5742 S 1475 E STE 100
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4857
Practice Address - Country:US
Practice Address - Phone:801-479-9070
Practice Address - Fax:801-479-9078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14515799241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356358535OtherINDIVIDUAL NPI TYPE 1
UT529989109028Medicaid
U19767Medicare UPIN