Healthcare Provider Details

I. General information

NPI: 1669482626
Provider Name (Legal Business Name): JOHN J ROCHE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 MAIN ST
CENTER MORICHES NY
11934
US

IV. Provider business mailing address

446 MAIN ST
CENTER MORICHES NY
11934
US

V. Phone/Fax

Practice location:
  • Phone: 631-878-3000
  • Fax:
Mailing address:
  • Phone: 631-878-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0449521
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: