Bradley Wane Roberts, D.M.D.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

019019769 Issued in IL

Practice address

4 Professional Dr
Alton, IL 62002-5067

Phone

(618) 465-9000

NPI assigned

May 21, 2010

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Feb 26, 2013 through Feb 26, 2027

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Bradley W Roberts DMD PC

  • Oral & Maxillofacial Surgery (D.M.D.)
  • Alton, IL
  • NPI 1396899878
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1274400000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1274400000000",
    "number": "1497074025",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4 PROFESSIONAL DR",
            "city": "ALTON",
            "state": "IL",
            "postal_code": "620025067",
            "telephone_number": "618-465-9000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4 PROFESSIONAL DR",
            "city": "ALTON",
            "state": "IL",
            "postal_code": "620025067",
            "telephone_number": "618-465-9000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROBERTS",
        "first_name": "BRADLEY",
        "middle_name": "WANE",
        "name_prefix": "Dr.",
        "credential": "D.M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2010-05-21",
        "last_updated": "2010-05-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "IL",
            "license": "019019769",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Riverbend Head Start & Family Services
• Miranda Walker Robbins, LCSW
• Regina Robeen, ASN,RN
• Roberta'S Lovely Ladies Boutique
• Robertas Lovely Ladies Boutique
• Kevin Brent Roberts, P.T.
• Sara B Roberts, RPH
• Janis M. Robinson, MD
• William P Robinson Jr., MD
• Katie Elizabeth Roderfeld

• Oral and Maxillofacial Surgery (Dentist) in Alton, IL
• Providers in Alton, IL by specialty
• Oral and Maxillofacial Surgery (Dentist) in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2010; 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; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.