Provider Demographics
NPI:1053491738
Name:ROACH, CHARLES DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
Last Name:ROACH
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 1:5959 TEMPLE RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37221-4114
Mailing Address - Country:US
Mailing Address - Phone:615-646-4088
Mailing Address - Fax:
Practice Address - Street 1:3817 BEDFORD AVE. UNIT 130
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215
Practice Address - Country:US
Practice Address - Phone:615-383-7801
Practice Address - Fax:615-297-2834
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS71651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice