Provider Demographics
NPI:1699228668
Name:ROAM, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:ROAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4TH WEST & VIRGINIA AVE
Mailing Address - Street 2:BLDG 500
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473
Mailing Address - Country:US
Mailing Address - Phone:573-596-0408
Mailing Address - Fax:
Practice Address - Street 1:5047 VIRGINIA AVE
Practice Address - Street 2:BLDG 500
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9126
Practice Address - Country:US
Practice Address - Phone:573-596-0408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant