Provider Demographics
NPI:1851992234
Name:ROACHE MCDONALD, ALTHEA
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:
Last Name:ROACHE MCDONALD
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 1:1060 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23860-1666
Mailing Address - Country:US
Mailing Address - Phone:804-504-7200
Mailing Address - Fax:804-504-7225
Practice Address - Street 1:1060 RIVER RD
Practice Address - Street 2:
Practice Address - City:NORTH PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23860-1666
Practice Address - Country:US
Practice Address - Phone:804-504-7200
Practice Address - Fax:804-504-7225
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043417-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice