Provider Demographics
NPI:1386663599
Name:ROE, TYSON JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:JAMES
Last Name:ROE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6004 CREEDMOOR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2209
Mailing Address - Country:US
Mailing Address - Phone:919-787-8770
Mailing Address - Fax:919-966-6798
Practice Address - Street 1:6004 CREEMOOR RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2209
Practice Address - Country:US
Practice Address - Phone:919-878-7707
Practice Address - Fax:919-896-6679
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC75791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice