Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1164871000 |
---|---|
Provider Name | Kaimen Dre'paul Roberson |
First Address | Fort Carson, CO 80913-4095 |
Second Address | Fort Carson, CO 80913 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2016 |
Last Update Date | 11/06/2018 |