Provider Demographics
NPI:1669579330
Name:HUMES, ROXAN CAROL (DDS)
Entity type:Individual
Prefix:DR
First Name:ROXAN
Middle Name:CAROL
Last Name:HUMES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 OLYMPIAD DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1131
Mailing Address - Country:US
Mailing Address - Phone:323-296-6170
Mailing Address - Fax:
Practice Address - Street 1:3756 SANTA ROSALIA DR
Practice Address - Street 2:500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3606
Practice Address - Country:US
Practice Address - Phone:323-294-1170
Practice Address - Fax:323-295-0286
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA410921223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU89090Medicare UPIN