Provider Demographics
NPI:1336365659
Name:ROOT, RONNY EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONNY
Middle Name:EDWARD
Last Name:ROOT
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 1:2118 NEDERLAND AVE
Mailing Address - Street 2:STE.#1
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-6058
Mailing Address - Country:US
Mailing Address - Phone:409-727-5619
Mailing Address - Fax:409-721-9489
Practice Address - Street 1:2118 NEDERLAND AVE
Practice Address - Street 2:STE.#1
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-6058
Practice Address - Country:US
Practice Address - Phone:409-727-5619
Practice Address - Fax:409-721-9489
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX132761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice