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General NPI Number Information
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NPI Number | 1083932230
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Entity Type | Individual
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Provider Name | SAMANTHA ROACH D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 05/12/2010
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Last Update Date | 12/02/2020
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Provider Practice Location Address
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Address Line | 15015 CIMARRON AVE
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City | ROSEMOUNT
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State | MN
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Zip | 55068-2771
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Country | US
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Telephone | 612-558-6033
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Fax |
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Provider Business Mailing Address
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Address Line | 4820 BRYANT AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55419-5359
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Country | US
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Telephone | 612-558-6033
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | R448
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | D13028
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License Number State | MN
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