Provider Demographics
NPI:1821138090
Name:PICKENS, ROGER ALVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALVIN
Last Name:PICKENS
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 1:291 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064-1207
Mailing Address - Country:US
Mailing Address - Phone:614-873-4413
Mailing Address - Fax:614-873-4413
Practice Address - Street 1:291 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:OH
Practice Address - Zip Code:43064-1207
Practice Address - Country:US
Practice Address - Phone:614-873-4413
Practice Address - Fax:614-873-4413
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13956122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist