Provider Demographics
NPI:1912414251
Name:6 DAY DENTAL GROUP - ROANOKE, PLLC
Entity Type:Organization
Organization Name:6 DAY DENTAL GROUP - ROANOKE, PLLC
Other - Org Name:6 DAY DENTAL & ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-512-0760
Mailing Address - Street 1:212 OLD GRANDE BLVD STE B224
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4277
Mailing Address - Country:US
Mailing Address - Phone:903-509-0505
Mailing Address - Fax:903-707-2073
Practice Address - Street 1:200 TX-114
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262
Practice Address - Country:US
Practice Address - Phone:817-567-8040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31033261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental