MEDICARE: ROTH POWELL & MANN II DDS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1245779123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROTH POWELL & MANN II DDS PA

Provider Business Mailing Address
First Line	:	5220 TALLOWTREE DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-4548
Country	:	US
Telephone Number	:	919-345-9511
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 GLENWOOD AVE STE 210
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27603-1452
Country	:	US
Telephone Number	:	919-670-4944
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CHRISTY BALDWIN
Credential	:
Telephone Number	:	919-345-9511

Provider Enumeration Date	:	02/13/2017
Last Update Date	:	02/13/2017

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