Provider Demographics
NPI:1326109216
Name:STEWART, ROGER PATRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:PATRICK
Last Name:STEWART
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 1:2920 MARIETTA HWY
Mailing Address - Street 2:SUITE 146
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8212
Mailing Address - Country:US
Mailing Address - Phone:770-704-6987
Mailing Address - Fax:
Practice Address - Street 1:2920 MARIETTA HWY
Practice Address - Street 2:SUITE 146
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8212
Practice Address - Country:US
Practice Address - Phone:770-704-6987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100599OtherAVESIS
GA9182355OtherDORAL