Provider Demographics
NPI:1467006650
Name:ROSHANROU, MEDYA (DDS)
Entity Type:Individual
Prefix:
First Name:MEDYA
Middle Name:
Last Name:ROSHANROU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5848 ABRAMS RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-1603
Mailing Address - Country:US
Mailing Address - Phone:214-545-0111
Mailing Address - Fax:
Practice Address - Street 1:5848 ABRAMS RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-1603
Practice Address - Country:US
Practice Address - Phone:214-545-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX356031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice