Healthcare Provider Details

I. General information

NPI: 1912949934
Provider Name (Legal Business Name): KENNETH SHERMAN ROLL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 N FRONT ST SUITE #8
KINGSTON NY
12401-3741
US

IV. Provider business mailing address

130 N FRONT ST SUITE #8
KINGSTON NY
12401-3741
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-8812
  • Fax: 845-338-9086
Mailing address:
  • Phone: 845-338-8812
  • Fax: 845-338-9086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number033037
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: