Provider Demographics
NPI:1194815415
Name:GILLESPIE, ROGER LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LEE
Last Name:GILLESPIE
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 1:23560 MADISON ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4708
Mailing Address - Country:US
Mailing Address - Phone:310-325-4155
Mailing Address - Fax:310-325-7368
Practice Address - Street 1:23560 MADISON ST
Practice Address - Street 2:SUITE 215
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4708
Practice Address - Country:US
Practice Address - Phone:310-325-4155
Practice Address - Fax:310-325-7368
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32080122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA952621011OtherTAX ID NUMBER