MEDICARE: DR. TYSON JAMES ROE DDS

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	NC7579	NC

General Provider Information

NPI Number	:	1386663599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYSON JAMES ROE DDS

Provider Business Mailing Address
First Line	:	6004 CREEDMOOR RD STE 100
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-2209
Country	:	US
Telephone Number	:	919-787-8770
Fax Number	:	919-966-6798

Provider Business Practice Location Address
First Line	:	6004 CREEMOOR RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-2209
Country	:	US
Telephone Number	:	919-878-7707
Fax Number	:	919-896-6679

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/29/2020

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