Provider Demographics
NPI:1417054313
Name:NISHIMURA, ROGER D (DDS,PC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
Last Name:NISHIMURA
Suffix:
Gender:M
Credentials:DDS,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 E 1ST AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-5806
Mailing Address - Country:US
Mailing Address - Phone:303-399-0400
Mailing Address - Fax:303-399-1897
Practice Address - Street 1:3300 E 1ST AVE STE 300
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5806
Practice Address - Country:US
Practice Address - Phone:303-399-0400
Practice Address - Fax:303-399-1897
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO51731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice