Healthcare Provider Details

I. General information

NPI: 1073674560
Provider Name (Legal Business Name): JAMES M ROADT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W23657050 BIG BEND DRIVE
BIG BEND WI
53103
US

IV. Provider business mailing address

W23657050 BIG BEND DRIVE
BIG BEND WI
53103
US

V. Phone/Fax

Practice location:
  • Phone: 262-662-1111
  • Fax: 262-622-2111
Mailing address:
  • Phone: 262-662-1111
  • Fax: 262-622-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3754015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: