Provider Demographics
NPI:1114079217
Name:SALOME, ROGER BRIAN (DDS)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:BRIAN
Last Name:SALOME
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 1:7598 N MESA
Mailing Address - Street 2:SUITE A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3518
Mailing Address - Country:US
Mailing Address - Phone:915-584-4472
Mailing Address - Fax:915-581-0737
Practice Address - Street 1:7598 N MESA
Practice Address - Street 2:SUITE A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3518
Practice Address - Country:US
Practice Address - Phone:915-584-4472
Practice Address - Fax:915-581-0737
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
145516OtherUCCI
D08997OtherBCBS