Provider Demographics
NPI:1720697659
Name:CHAVEZ, ROXANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROXANA
Middle Name:
Last Name:CHAVEZ
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:SOUTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8501 BENBROOK BLVD STE 231
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126-2156
Practice Address - Country:US
Practice Address - Phone:817-529-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363961223X0008X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX416510201Medicaid