Provider Demographics
NPI:1881820843
Name:ROACH, BRYAN PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:PATRICK
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:ADVANCED EDUCATION IN GENERAL DENTISTRY PROGRAM
Mailing Address - Street 2:2300 RAMSEY ST.
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-3856
Mailing Address - Country:US
Mailing Address - Phone:910-822-7029
Mailing Address - Fax:910-482-5050
Practice Address - Street 1:ADVANCED EDUCATION IN GENERAL DENTISTRY PROGRAM
Practice Address - Street 2:2300 RAMSEY ST.
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3856
Practice Address - Country:US
Practice Address - Phone:910-822-7029
Practice Address - Fax:910-482-5050
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8774122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist