Provider Demographics
NPI:1972706919
Name:ROANE, MATTHEW A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:ROANE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 10TH STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068
Mailing Address - Country:US
Mailing Address - Phone:503-657-1215
Mailing Address - Fax:503-657-8307
Practice Address - Street 1:1673 10TH STREET
Practice Address - Street 2:SUITE B
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068
Practice Address - Country:US
Practice Address - Phone:503-657-1215
Practice Address - Fax:503-657-8307
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6622694-99221223G0001X
OR9064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice