Provider Demographics
NPI:1831320738
Name:ROACH, DALE SIMON (MD, LAC)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:SIMON
Last Name:ROACH
Suffix:
Gender:M
Credentials:MD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-2310
Mailing Address - Country:US
Mailing Address - Phone:914-562-5742
Mailing Address - Fax:914-699-7510
Practice Address - Street 1:289 PRIMROSE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-2310
Practice Address - Country:US
Practice Address - Phone:914-562-5742
Practice Address - Fax:914-699-7510
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003244171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist