Provider Demographics
NPI:1659474021
Name:FEDERICO, ROLAND ADRIEN (DDS)
Entity Type:Individual
Prefix:MR
First Name:ROLAND
Middle Name:ADRIEN
Last Name:FEDERICO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 KINGSLEY AVENUE
Mailing Address - Street 2:BUILDING 9F
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4579
Mailing Address - Country:US
Mailing Address - Phone:904-264-5806
Mailing Address - Fax:904-264-6323
Practice Address - Street 1:1409 KINGSLEY AVENUE
Practice Address - Street 2:BUILDING 9F
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4579
Practice Address - Country:US
Practice Address - Phone:904-264-5806
Practice Address - Fax:904-264-6323
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5486122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist