Provider Demographics
NPI:1083932230
Name:ROACH, SAMANTHA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4820 BRYANT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5359
Mailing Address - Country:US
Mailing Address - Phone:612-558-6033
Mailing Address - Fax:
Practice Address - Street 1:15015 CIMARRON AVE
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-2771
Practice Address - Country:US
Practice Address - Phone:612-558-6033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR448122300000X
MND130281223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist