Provider Demographics
NPI:1598920472
Name:ROMAN, MARK A (DMD FAGD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ROMAN
Suffix:
Gender:M
Credentials:DMD FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 FRONT STREET
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:NY
Mailing Address - Zip Code:14801
Mailing Address - Country:US
Mailing Address - Phone:607-359-3367
Mailing Address - Fax:607-359-3399
Practice Address - Street 1:138 FRONT STREET
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:NY
Practice Address - Zip Code:14801
Practice Address - Country:US
Practice Address - Phone:607-359-3367
Practice Address - Fax:607-359-3399
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY42738-11122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist