Provider Demographics
NPI:1114949294
Name:ROLLER, BRANDON SCOTT (DMD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:SCOTT
Last Name:ROLLER
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 1:401 EDGEMONT AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620
Mailing Address - Country:US
Mailing Address - Phone:423-968-4422
Mailing Address - Fax:423-968-3477
Practice Address - Street 1:401 EDGEMONT AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-2314
Practice Address - Country:US
Practice Address - Phone:423-968-4422
Practice Address - Fax:423-968-3477
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000084071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice