Provider Demographics
NPI:1124514203
Name:R. DOUGLAS ROSS, DDS PC
Entity type:Organization
Organization Name:R. DOUGLAS ROSS, DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-344-9361
Mailing Address - Street 1:1602 GRANDIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2308
Mailing Address - Country:US
Mailing Address - Phone:540-344-9361
Mailing Address - Fax:540-344-9377
Practice Address - Street 1:1602 GRANDIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2308
Practice Address - Country:US
Practice Address - Phone:540-344-9361
Practice Address - Fax:540-344-9377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007069261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922141811OtherINDIVIDUAL NPI