Provider Demographics
NPI:1689185621
Name:ROACH, JEANETTE GERMAINE (RDH)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:GERMAINE
Last Name:ROACH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 BRADLEY LN
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-4595
Mailing Address - Country:US
Mailing Address - Phone:214-422-9273
Mailing Address - Fax:
Practice Address - Street 1:2423 WILLIAMS DR STE 107
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3269
Practice Address - Country:US
Practice Address - Phone:512-686-0207
Practice Address - Fax:512-868-3239
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15179124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist