Provider Demographics
NPI:1093384356
Name:ROACH, KALIN MCCABE
Entity type:Individual
Prefix:
First Name:KALIN
Middle Name:MCCABE
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BASSETT LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6500
Mailing Address - Country:US
Mailing Address - Phone:601-395-6017
Mailing Address - Fax:
Practice Address - Street 1:1425 SIMPSON, US 49
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3911
Practice Address - Country:US
Practice Address - Phone:601-849-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4208-21122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist