Healthcare Provider Details

I. General information

NPI: 1679960231
Provider Name (Legal Business Name): ROADS DENTAL SPECIALTY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1378 CORAL WAY 5TH FLOOR
MIAMI FL
33145-2943
US

IV. Provider business mailing address

1378 CORAL WAY 5TH FLOOR
MIAMI FL
33145-2943
US

V. Phone/Fax

Practice location:
  • Phone: 305-856-1134
  • Fax: 305-239-9452
Mailing address:
  • Phone: 305-856-1134
  • Fax: 305-239-9452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSICA C EAGAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 305-856-1134