1295804011 NPI number — RICHARD JOHN ROMAN DDS

Table of content: RICHARD JOHN ROMAN DDS (NPI 1295804011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295804011 NPI number — RICHARD JOHN ROMAN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROMAN
Provider First Name:
RICHARD
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295804011
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 COUNTRYSIDE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ACTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-263-7988
Provider Business Mailing Address Fax Number:
978-263-8424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
296 GREAT ROAD
Provider Second Line Business Practice Location Address:
GREAT ROAD DENTAL ASSOCS
Provider Business Practice Location Address City Name:
ACTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-263-8525
Provider Business Practice Location Address Fax Number:
978-263-2955
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  11913 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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