Provider Demographics
NPI:1245779123
Name:ROTH POWELL & MANN II DDS PA
Entity Type:Organization
Organization Name:ROTH POWELL & MANN II DDS PA
Other - Org Name:CAROLINA@GLENWOOD SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-345-9511
Mailing Address - Street 1:5220 TALLOWTREE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-4548
Mailing Address - Country:US
Mailing Address - Phone:919-345-9511
Mailing Address - Fax:
Practice Address - Street 1:301 GLENWOOD AVE STE 210
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-1452
Practice Address - Country:US
Practice Address - Phone:919-670-4944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty