Provider Demographics
NPI:1902138795
Name:JOHN R. ROLLER, D.D.S.
Entity Type:Organization
Organization Name:JOHN R. ROLLER, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-943-1114
Mailing Address - Street 1:436 S LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-3564
Mailing Address - Country:US
Mailing Address - Phone:540-943-1114
Mailing Address - Fax:
Practice Address - Street 1:436 S LINDEN AVE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-3564
Practice Address - Country:US
Practice Address - Phone:540-943-1114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN R. ROLLER, D.D.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401004700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty