Provider Demographics
NPI:1497169932
Name:DAVID HENRY DDS AND RANDELL ROARK DDS INC.
Entity Type:Organization
Organization Name:DAVID HENRY DDS AND RANDELL ROARK DDS INC.
Other - Org Name:CRICKET LANE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/ VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDELL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-584-6894
Mailing Address - Street 1:1041 CRICKET LN
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-4105
Mailing Address - Country:US
Mailing Address - Phone:419-526-4249
Mailing Address - Fax:
Practice Address - Street 1:1041 CRICKET LN
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4105
Practice Address - Country:US
Practice Address - Phone:419-526-4249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH217721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0076483Medicaid
OH0489403Medicaid
OH2860159Medicaid