MEDICARE: DEVON ROESE 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	1223P0221X	Pediatric Dentistry	11201	KY
2	1223P0221X	Pediatric Dentistry	30.028370	OH

General Provider Information

NPI Number	:	1770260622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVON ROESE DDS

Provider Business Mailing Address
First Line	:	4787 HOUSTON RD APT 1301
Second Line	:
City	:	FLORENCE
State	:	KY
Zip	:	41042-4809
Country	:	US
Telephone Number	:	812-374-7091
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 TOWN CENTER BLVD STE 202
Second Line	:
City	:	CRESTVIEW HILLS
State	:	KY
Zip	:	41017-2417
Country	:	US
Telephone Number	:	859-344-6200
Fax Number	:

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

Provider Enumeration Date	:	07/03/2023
Last Update Date	:	06/17/2026

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