Provider Demographics
NPI:1619364858
Name:ROACH, ZACHARY THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:THOMAS
Last Name:ROACH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34359 CARPENTERS WAY
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-4910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34359 CARPENTERS WAY
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-4910
Practice Address - Country:US
Practice Address - Phone:302-645-8993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DEG1-00013741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program