Healthcare Provider Details

I. General information

NPI: 1134753304
Provider Name (Legal Business Name): ROKSOLANA GALA DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 MARTIN LUTHER KING JR BLVD
DETROIT MI
48208-2576
US

IV. Provider business mailing address

2700 MARTIN LUTHER KING JR BLVD
DETROIT MI
48208
US

V. Phone/Fax

Practice location:
  • Phone: 313-494-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901601877
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: