Provider Demographics
NPI:1790793065
Name:ROEH, PAUL E (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:ROEH
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 1:109 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2351
Mailing Address - Country:US
Mailing Address - Phone:361-575-1151
Mailing Address - Fax:
Practice Address - Street 1:109 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2351
Practice Address - Country:US
Practice Address - Phone:361-575-1151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB09112-1OtherCHILDRENS HEALTH INSURANC
TX091004401Medicaid