Healthcare Provider Details

I. General information

NPI: 1598524373
Provider Name (Legal Business Name): MONICA ROACH EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S 17TH ST
HARRISBURG PA
17104-1123
US

IV. Provider business mailing address

110 S 17TH ST
HARRISBURG PA
17104-1123
US

V. Phone/Fax

Practice location:
  • Phone: 717-232-9971
  • Fax: 717-231-5761
Mailing address:
  • Phone: 717-232-9971
  • Fax: 717-231-5761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberDF003703
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: