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General NPI Number Information
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NPI Number | 1093044406
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Entity Type | Organization
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Legal Business Name | GARY A. ROACH, DDS, LTD
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Dates
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Enumeration Date | 12/14/2009
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Last Update Date | 12/14/2009
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Provider Practice Location Address
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Address Line | 5004 BRAMBLETON AVE
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City | ROANOKE
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State | VA
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Zip | 24018-4642
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Country | US
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Telephone | 540-774-1019
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Fax | 540-774-9012
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Provider Business Mailing Address
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Address Line | 5004 BRAMBLETON AVE
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City | ROANOKE
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State | VA
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Zip | 24018-4642
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Country | US
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Telephone | 540-774-1019
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Fax | 540-774-9012
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. GARY A ROACH
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Credential | DDS
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Telephone | 540-774-1019
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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 | 0401411406
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401008066
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License Number State | WV
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401007932
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License Number State | VA
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