Provider Demographics
NPI:1225640865
Name:DR. ROGER C. STODDARD DDS, PA
Entity Type:Organization
Organization Name:DR. ROGER C. STODDARD DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:651-776-1597
Mailing Address - Street 1:2480 WHITE BEAR AVE N STE 202
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-4567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2480 WHITE BEAR AVE N STE 202
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-4567
Practice Address - Country:US
Practice Address - Phone:651-776-1597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental