NPIMap

Organization Active NPI

David Henry DDS and Randell Roark DDS Inc.

Doing business as Cricket Lane Dental

  • General Practice Dentistry
  • Mansfield, OH
National Provider Identifier
1497169932
Registry record updated Jun 12, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
21772 Issued in OH
Legal business name
DAVID HENRY DDS AND RANDELL ROARK DDS INC.
Doing business as
Cricket Lane Dental
Practice address
1041 Cricket LN
Mansfield, OH 44906-4105
Phone
(419) 526-4249
NPI assigned
Jun 12, 2014
Last updated
Jun 12, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Randell Scott Roark, DDS
Title
Dentist/ Vice President
Phone
(910) 584-6894

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X 21772 OH Primary

Addresses

Primary practice location

1041 Cricket LN
Mansfield, OH 44906-4105

Mailing address

1041 Cricket LN
Mansfield, OH 44906-4105
Phone (419) 526-4249

Other identifiers 3

IdentifierTypeStateIssuer
0489403MedicaidOH
0076483MedicaidOH
2860159MedicaidOH

Other names 1

  • Cricket Lane Dental Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Cricket Lane Dental2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1402531200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1402531200000",
    "number": "1497169932",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1041 CRICKET LN",
            "city": "MANSFIELD",
            "state": "OH",
            "postal_code": "449064105",
            "telephone_number": "419-526-4249"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1041 CRICKET LN",
            "city": "MANSFIELD",
            "state": "OH",
            "postal_code": "449064105",
            "telephone_number": "419-526-4249"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DAVID HENRY DDS AND RANDELL ROARK DDS INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-06-12",
        "last_updated": "2014-06-12",
        "status": "A",
        "authorized_official_last_name": "ROARK",
        "authorized_official_first_name": "RANDELL",
        "authorized_official_middle_name": "SCOTT",
        "authorized_official_title_or_position": "DENTIST/ VICE PRESIDENT",
        "authorized_official_telephone_number": "910-584-6894",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "OH",
            "license": "21772",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0489403",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0076483",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2860159",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cricket Lane Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mansfield, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.