=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063609295
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP ROE DDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2007
-----------------------------------------------------
Last Update Date | 01/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3133 W FRYE RD STE 102
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85226-5132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-542-5617
-----------------------------------------------------
Fax | 480-542-5618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3133 W FRYE RD STE 102
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85226-5132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-542-5617
-----------------------------------------------------
Fax | 480-542-5618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 00009710
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 52776
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | D010253
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------