Provider Demographics
NPI:1003002791
Name:ROLLE, ELIZABETH MARY (RDH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY
Last Name:ROLLE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 WALKER DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-2938
Mailing Address - Country:US
Mailing Address - Phone:406-327-0292
Mailing Address - Fax:
Practice Address - Street 1:323 W ALDER ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4123
Practice Address - Country:US
Practice Address - Phone:406-258-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1051124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist