Provider Demographics
NPI:1023306362
Name:ROACH, BARTHOLOMEW SULLIVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:BARTHOLOMEW
Middle Name:SULLIVAN
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 1:10201 W CLEARWATER AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8588
Mailing Address - Country:US
Mailing Address - Phone:509-735-8521
Mailing Address - Fax:
Practice Address - Street 1:10201 W CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8588
Practice Address - Country:US
Practice Address - Phone:509-735-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE69511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice