Provider Demographics
NPI:1093925232
Name:ROEDIGER, GORDON KENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:KENT
Last Name:ROEDIGER
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 1:5190 E FARNESS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2142
Mailing Address - Country:US
Mailing Address - Phone:520-795-3773
Mailing Address - Fax:520-795-4008
Practice Address - Street 1:5190 E FARNESS DR STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2142
Practice Address - Country:US
Practice Address - Phone:520-795-3773
Practice Address - Fax:520-795-4008
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23851223G0001X
AZ61791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice