Provider Demographics
NPI:1801072905
Name:BROMAN, ROBERTA JO (RDH)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:JO
Last Name:BROMAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:BOBBIE
Other - Middle Name:
Other - Last Name:BROMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDH
Mailing Address - Street 1:3202 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212
Mailing Address - Country:US
Mailing Address - Phone:719-671-5110
Mailing Address - Fax:
Practice Address - Street 1:1215 N 15TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4620
Practice Address - Country:US
Practice Address - Phone:719-269-7194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH903830124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist