Active NPI
Glen Allen Roberson, DMD
- Orthodontics and Dentofacial Orthopedics Dentistry
- Las Vegas, NV
National Provider Identifier
1144434275
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Orthodontics and Dentofacial Orthopedics Dentistry
- License
- LL-0107-06
- Practice address
- 9687 Blue Calico Dr
Las Vegas, NV 89123-5825 - Phone
- (973) 202-3272
- NPI assigned
- May 9, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | LL-0107-06 | NV | Primary |
Addresses
Primary practice location
9687 Blue Calico Dr
Las Vegas, NV 89123-5825
Mailing address
9687 Blue Calico Dr
Las Vegas, NV 89123-5825
Phone (973) 202-3272
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NV
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180820001684 | NV | Order and Referring Only - Other (Physician) | 5496004756 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LL-0107-06 | NV | MD | Orthodontics and Dentofacial Orthopedic Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1178668800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1144434275",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9687 BLUE CALICO DR",
"city": "LAS VEGAS",
"state": "NV",
"postal_code": "891235825",
"telephone_number": "973-202-3272"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9687 BLUE CALICO DR",
"city": "LAS VEGAS",
"state": "NV",
"postal_code": "891235825",
"telephone_number": "973-202-3272"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROBERSON",
"first_name": "GLEN",
"middle_name": "ALLEN",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-05-09",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223X0400X",
"taxonomy_group": "",
"desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
"state": "NV",
"license": "LL-0107-06",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Las Vegas, NV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.