Provider Demographics
NPI:1427459049
Name:BRUCE T. ROACH, D.D.S., P.C.
Entity type:Organization
Organization Name:BRUCE T. ROACH, D.D.S., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-673-2400
Mailing Address - Street 1:5270 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1913
Mailing Address - Country:US
Mailing Address - Phone:248-673-2400
Mailing Address - Fax:248-673-8663
Practice Address - Street 1:5270 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1913
Practice Address - Country:US
Practice Address - Phone:248-673-2400
Practice Address - Fax:248-673-8663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI129161223G0001X
MI201491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty