Provider Demographics
NPI:1821053521
Name:LAWRENCE, ROGER BRENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:BRENT
Last Name:LAWRENCE
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 1:5415 SW WESTGATE DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2409
Mailing Address - Country:US
Mailing Address - Phone:503-292-1173
Mailing Address - Fax:503-291-0353
Practice Address - Street 1:5415 SW WESTGATE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2409
Practice Address - Country:US
Practice Address - Phone:503-292-1173
Practice Address - Fax:503-291-0353
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD63741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice