Provider Demographics
NPI:1467430538
Name:CHILDRESS, ROGER WILLIAM (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WILLIAM
Last Name:CHILDRESS
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Gender:M
Credentials:DDS, MD
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Mailing Address - Street 1:1350 MACKEY BRANCH DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421
Mailing Address - Country:US
Mailing Address - Phone:423-296-8210
Mailing Address - Fax:423-296-8292
Practice Address - Street 1:1350 MACKEY BRANCH DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-296-8210
Practice Address - Fax:423-296-8292
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDS51321223S0112X
TNMS341491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery