Provider Demographics
NPI:1225123219
Name:KOLARICH, ROGER WHITMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WHITMAN
Last Name:KOLARICH
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:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:POSTVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52162
Mailing Address - Country:US
Mailing Address - Phone:563-864-7818
Mailing Address - Fax:563-864-7685
Practice Address - Street 1:111 E TILDEN ST
Practice Address - Street 2:
Practice Address - City:POSTVILLE
Practice Address - State:IA
Practice Address - Zip Code:52162
Practice Address - Country:US
Practice Address - Phone:563-864-7818
Practice Address - Fax:563-864-7685
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0169227Medicaid