Provider Demographics
NPI:1417155417
Name:JOLLYVILLE DENTAL PROFESSIONALS
Entity Type:Organization
Organization Name:JOLLYVILLE DENTAL PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-918-0005
Mailing Address - Street 1:11672 JOLLYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3935
Mailing Address - Country:US
Mailing Address - Phone:512-918-0005
Mailing Address - Fax:512-918-0008
Practice Address - Street 1:11672 JOLLYVILLE RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3935
Practice Address - Country:US
Practice Address - Phone:512-918-0005
Practice Address - Fax:512-918-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX132191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty