Provider Demographics
NPI:1821043761
Name:ROACH, BRUCE T (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:T
Last Name:ROACH
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 1:5270 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1913
Mailing Address - Country:US
Mailing Address - Phone:248-673-2400
Mailing Address - Fax:248-673-8663
Practice Address - Street 1:5270 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1913
Practice Address - Country:US
Practice Address - Phone:248-673-2400
Practice Address - Fax:248-673-8663
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0129161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1656335Medicaid