Provider Demographics
NPI:1215014998
Name:ROUBAL, ROGER WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WILLIAM
Last Name:ROUBAL
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 1:11919 GRANT ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3475
Mailing Address - Country:US
Mailing Address - Phone:402-493-4175
Mailing Address - Fax:402-493-9273
Practice Address - Street 1:11919 GRANT ST
Practice Address - Street 2:SUITE 140
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3475
Practice Address - Country:US
Practice Address - Phone:402-493-4175
Practice Address - Fax:402-493-9273
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE43391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEU27684Medicare UPIN
NE090874Medicare ID - Type Unspecified