Provider Demographics
NPI:1669114245
Name:ROMAN, ANNA KAY (DDS)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:KAY
Last Name:ROMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:KAY
Other - Last Name:IBBERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 SOUTHDALE ST SE
Mailing Address - Street 2:
Mailing Address - City:SLEEPY EYE
Mailing Address - State:MN
Mailing Address - Zip Code:56085-1875
Mailing Address - Country:US
Mailing Address - Phone:507-227-0187
Mailing Address - Fax:
Practice Address - Street 1:1700 W CHARLESTON BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2335
Practice Address - Country:US
Practice Address - Phone:702-774-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV76691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice