Provider Demographics
NPI:1083011159
Name:ROEDER, JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:ROEDER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 DARBY RD
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1475
Mailing Address - Country:US
Mailing Address - Phone:610-647-7272
Mailing Address - Fax:610-647-7278
Practice Address - Street 1:45 DARBY RD
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1475
Practice Address - Country:US
Practice Address - Phone:610-647-7272
Practice Address - Fax:610-647-7278
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0309291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice