Provider Demographics
NPI:1639318116
Name:WIRTZ, ROGER STEPHENSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:STEPHENSON
Last Name:WIRTZ
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 1:1765 LELIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4820
Mailing Address - Country:US
Mailing Address - Phone:601-982-5349
Mailing Address - Fax:601-982-9084
Practice Address - Street 1:1765 LELIA DR.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4820
Practice Address - Country:US
Practice Address - Phone:601-982-5349
Practice Address - Fax:601-982-9084
Is Sole Proprietor?:No
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2040-831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice