Provider Demographics
NPI:1265562235
Name:ROACH, PHILIP C (DDS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
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 1:2121 E DUPONT RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1546
Mailing Address - Country:US
Mailing Address - Phone:260-489-1818
Mailing Address - Fax:260-490-1705
Practice Address - Street 1:2121 E DUPONT RD
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1546
Practice Address - Country:US
Practice Address - Phone:260-489-1818
Practice Address - Fax:260-490-1705
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008612A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1001318160Medicare ID - Type Unspecified