Provider Demographics
NPI:1992966394
Name:ROUBAL, THOMAS A (DDS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:ROUBAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17730 LORAIN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-1837
Mailing Address - Country:US
Mailing Address - Phone:216-476-3888
Mailing Address - Fax:216-476-3892
Practice Address - Street 1:17730 LORAIN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-4091
Practice Address - Country:US
Practice Address - Phone:216-476-3888
Practice Address - Fax:216-476-3892
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14711122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist