Provider Demographics
NPI:1295920502
Name:ROACH, CORY W (DDS)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:W
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:PO BOX 10070
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76547-0070
Mailing Address - Country:US
Mailing Address - Phone:254-634-3811
Mailing Address - Fax:254-634-6851
Practice Address - Street 1:602 E ELMS RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-6030
Practice Address - Country:US
Practice Address - Phone:254-634-3811
Practice Address - Fax:254-634-6851
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21755122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist