Provider Demographics
NPI:1265505515
Name:PHANORD, ROGER JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:JOSEPH
Last Name:PHANORD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5337 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-2707
Mailing Address - Country:US
Mailing Address - Phone:305-758-0815
Mailing Address - Fax:305-758-5030
Practice Address - Street 1:5337 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-2707
Practice Address - Country:US
Practice Address - Phone:305-758-0815
Practice Address - Fax:305-758-5030
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0011339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist