Provider Demographics
NPI:1407905698
Name:ROARK, RODNEY JOE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:JOE
Last Name:ROARK
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 1:4102 N MALL AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4911
Mailing Address - Country:US
Mailing Address - Phone:479-442-2424
Mailing Address - Fax:479-442-9325
Practice Address - Street 1:4102 N MALL AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4911
Practice Address - Country:US
Practice Address - Phone:479-442-2424
Practice Address - Fax:479-442-9325
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR31361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR3136OtherLISCENSE NUMBER