Provider Demographics
NPI:1457444143
Name:THRONDSON, ROGER R (DDS)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:R
Last Name:THRONDSON
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 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-747-0890
Mailing Address - Fax:409-772-0885
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-5302
Practice Address - Country:US
Practice Address - Phone:409-772-0817
Practice Address - Fax:409-772-0885
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX173751223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111228602Medicaid
TXU76359Medicare UPIN
TX8232J9Medicare ID - Type Unspecified