Provider Demographics
NPI:1255061354
Name:NOVA TELEDENTISTRY
Entity type:Organization
Organization Name:NOVA TELEDENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCCANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-540-0737
Mailing Address - Street 1:7451 AUBURN BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-2992
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8111 AZTEC WAY
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-4411
Practice Address - Country:US
Practice Address - Phone:916-540-0737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD5352890OtherDL