Provider Demographics
NPI:1598840340
Name:ROACH, BRANDI RACHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDI
Middle Name:RACHELLE
Last Name:ROACH
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 1:2707 W HUNTSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-7723
Mailing Address - Country:US
Mailing Address - Phone:479-756-8631
Mailing Address - Fax:479-751-7892
Practice Address - Street 1:2707 W HUNTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-7723
Practice Address - Country:US
Practice Address - Phone:479-756-8631
Practice Address - Fax:479-751-7892
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR3363OtherDELTA
AR58250OtherBCBS
AR1317596Medicaid
AR1317596Medicaid