Provider Demographics
NPI:1083190011
Name:ROE, KAYLA MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:ROE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 N MILWAUKEE AVE UNIT 2-3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-4188
Mailing Address - Country:US
Mailing Address - Phone:804-840-7170
Mailing Address - Fax:
Practice Address - Street 1:6605 W BROAD ST STE 105
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1714
Practice Address - Country:US
Practice Address - Phone:804-495-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014167611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice