Provider Demographics
NPI:1790762375
Name:WAHLMAN, ROGER (DDS)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:WAHLMAN
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:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:ALTAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95221-0820
Mailing Address - Country:US
Mailing Address - Phone:209-736-4641
Mailing Address - Fax:
Practice Address - Street 1:571 STANISLAUS AVE.
Practice Address - Street 2:
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95221
Practice Address - Country:US
Practice Address - Phone:209-736-4641
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA233941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice