Provider Demographics
NPI:1659403848
Name:STANEK, ROGER GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:GARY
Last Name:STANEK
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 1:315 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-4355
Mailing Address - Country:US
Mailing Address - Phone:920-731-2211
Mailing Address - Fax:
Practice Address - Street 1:315 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-4355
Practice Address - Country:US
Practice Address - Phone:920-731-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1138G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice