Provider Demographics
NPI:1558469718
Name:KITZIS, ROGER (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:KITZIS
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 1:156 PLAINVIEW RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797
Mailing Address - Country:US
Mailing Address - Phone:516-692-7766
Mailing Address - Fax:631-692-6129
Practice Address - Street 1:156 PLAINVIEW RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797
Practice Address - Country:US
Practice Address - Phone:516-692-7766
Practice Address - Fax:631-692-6129
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04014511223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D9G951Medicare UPIN