Provider Demographics
NPI:1003819970
Name:THOMPSON, ROGER W (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:D
Other - Last Name:SCHROYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:201 N RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-5491
Mailing Address - Country:US
Mailing Address - Phone:810-329-2289
Mailing Address - Fax:
Practice Address - Street 1:201 N RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-5491
Practice Address - Country:US
Practice Address - Phone:810-329-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI105781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice