Basic Information
| Provider Information | |||||||||
| NPI: | 1023231271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044570099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077946700 | ||||||||
| FaxNumber: | 2077946777 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 MAIN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LINCOLN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044571216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077946700 | ||||||||
| FaxNumber: | 2077946777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 11/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2543 | ME | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 161040200 | 05 | ME | MEDICAID |