Provider Demographics
NPI:1083085401
Name:ROLLE, MAXIME JEAN MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:MAXIME
Middle Name:JEAN MARIE
Last Name:ROLLE
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 1:25967 REDLANDS BLVD APT D
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8480
Mailing Address - Country:US
Mailing Address - Phone:909-302-3869
Mailing Address - Fax:
Practice Address - Street 1:25590 PROSPECT AVE APT 18A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3147
Practice Address - Country:US
Practice Address - Phone:909-302-3869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist