Provider Demographics
NPI:1407889421
Name:ROZANOV, ROMAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:ROZANOV
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 1:1617 JOHN F KENNEDY BLVD STE 855
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1841
Mailing Address - Country:US
Mailing Address - Phone:215-557-0660
Mailing Address - Fax:215-557-0662
Practice Address - Street 1:1880 JOHN F KENNEDY BLVD STE 403
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-7407
Practice Address - Country:US
Practice Address - Phone:215-557-0660
Practice Address - Fax:215-557-0661
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-030197-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice