Provider Demographics
NPI:1023001831
Name:ROMAN, IVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:ROMAN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3259 CATLIN AVE
Mailing Address - Street 2:NAVAL HEALTH CLINIC QUANTICO
Mailing Address - City:QUANTICO
Mailing Address - State:VA
Mailing Address - Zip Code:22134
Mailing Address - Country:US
Mailing Address - Phone:703-784-2802
Mailing Address - Fax:
Practice Address - Street 1:PSC 482 BOX 1600
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362-0017
Practice Address - Country:US
Practice Address - Phone:098-971-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA401141223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics