Provider Demographics
NPI:1013082304
Name:THOMPSON, ROGER L
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ROGER
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6496 N PIQUA RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733
Mailing Address - Country:US
Mailing Address - Phone:260-724-8746
Mailing Address - Fax:260-724-2175
Practice Address - Street 1:6496 N PIQUA RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-9434
Practice Address - Country:US
Practice Address - Phone:260-724-8746
Practice Address - Fax:260-724-2175
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN6751122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist