Provider Demographics
NPI:1053005504
Name:SHOUBAKI, ROANNE
Entity type:Individual
Prefix:
First Name:ROANNE
Middle Name:
Last Name:SHOUBAKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2411 WILLIAMS DR STE 111
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3268
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39434122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist