Provider Demographics
NPI:1801001482
Name:NEILL, ROGER WILLIAM (DMD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WILLIAM
Last Name:NEILL
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 1:90 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-5735
Mailing Address - Country:US
Mailing Address - Phone:518-891-0104
Mailing Address - Fax:518-891-7130
Practice Address - Street 1:90 MAIN ST
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5735
Practice Address - Country:US
Practice Address - Phone:518-891-0104
Practice Address - Fax:518-891-7130
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist