Provider Demographics
NPI:1700518560
Name:ROMAN, AGNIESZKA ANNA (DDS)
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:ANNA
Last Name:ROMAN
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 1:510 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-9990
Mailing Address - Country:US
Mailing Address - Phone:804-506-0808
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9991
Practice Address - Country:US
Practice Address - Phone:800-817-3807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014187571223G0001X
MD175441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice