Provider Demographics
NPI:1609955772
Name:DIMICK, ROGER DONALD (DMD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DONALD
Last Name:DIMICK
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 1:5060 GREENSBOROUGH CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8748
Mailing Address - Country:US
Mailing Address - Phone:503-670-7088
Mailing Address - Fax:503-443-1448
Practice Address - Street 1:11565 SW HALL BLVD STE C
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8493
Practice Address - Country:US
Practice Address - Phone:503-670-7088
Practice Address - Fax:503-443-1448
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR43191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice