Provider Demographics
NPI:1679140941
Name:ROACH, NICHOLAS B (DDS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:B
Last Name:ROACH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-1257
Mailing Address - Country:US
Mailing Address - Phone:330-469-0487
Mailing Address - Fax:614-321-6799
Practice Address - Street 1:107 W COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-1257
Practice Address - Country:US
Practice Address - Phone:330-469-0487
Practice Address - Fax:614-321-6799
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist