Provider Demographics
NPI:1346689791
Name:DENTAL 192
Entity Type:Organization
Organization Name:DENTAL 192
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROPPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-551-5423
Mailing Address - Street 1:100 W NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4303
Mailing Address - Country:US
Mailing Address - Phone:630-659-5293
Mailing Address - Fax:
Practice Address - Street 1:100 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4303
Practice Address - Country:US
Practice Address - Phone:630-659-5293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN177241223G0001X
FLDN176811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty