MEDICARE: DR. VICTORIA J. ROEDER D.D.S.

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	1223P0221X	Pediatric Dentistry	DI20385	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	90001024500	OTHER	NJ	AMERICHOICE
2	UNITED CONCORDIA	OTHER	NJ	869326
3	2120385	OTHER	NJ	DELTA

General Provider Information

NPI Number	:	1720160906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICTORIA J. ROEDER D.D.S.

Provider Business Mailing Address
First Line	:	211 W MILLSTREAM RD
Second Line	:
City	:	CREAM RIDGE
State	:	NJ
Zip	:	08514-2356
Country	:	US
Telephone Number	:	609-758-9595
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 W MILLSTREAM RD
Second Line	:
City	:	CREAM RIDGE
State	:	NJ
Zip	:	08514-2356
Country	:	US
Telephone Number	:	609-758-9595
Fax Number	:

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

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	07/08/2007

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