Provider Demographics
NPI:1780806455
Name:MLCAK, ROXANE G (DDS)
Entity type:Individual
Prefix:DR
First Name:ROXANE
Middle Name:G
Last Name:MLCAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ROXANE
Other - Middle Name:G
Other - Last Name:MLCAK-SPENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1605 ROCK PRAIRIE RD STE 214
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8358
Mailing Address - Country:US
Mailing Address - Phone:979-696-4511
Mailing Address - Fax:
Practice Address - Street 1:1605 ROCK PRAIRIE RD STE 214
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8358
Practice Address - Country:US
Practice Address - Phone:979-696-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX157451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82D692OtherBCBS PROVIDER #