Provider Demographics
NPI:1821152455
Name:ROA, CARLOS JUAN
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:JUAN
Last Name:ROA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 316
Mailing Address - Street 2:607 SOUTH FOURTH STREET SUITE B
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523
Mailing Address - Country:US
Mailing Address - Phone:309-274-6237
Mailing Address - Fax:309-274-2144
Practice Address - Street 1:607 SOUTH FOURTH STREET
Practice Address - Street 2:SUITE B
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523
Practice Address - Country:US
Practice Address - Phone:309-274-6237
Practice Address - Fax:309-274-2144
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist