Healthcare Provider Details

I. General information

NPI: 1700518560
Provider Name (Legal Business Name): AGNIESZKA ANNA ROMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 04/08/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BUTLER AVE
MARTINSBURG WV
25405-9991
US

IV. Provider business mailing address

510 BUTLER AVE
MARTINSBURG WV
25405-9990
US

V. Phone/Fax

Practice location:
  • Phone: 800-817-3807
  • Fax:
Mailing address:
  • Phone: 804-506-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401418757
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17544
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: