Provider Demographics
NPI:1205949633
Name:HOLLISTER, ROGER STUART (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:STUART
Last Name:HOLLISTER
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 1:724 S CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-2204
Mailing Address - Country:US
Mailing Address - Phone:310-686-8546
Mailing Address - Fax:214-467-5268
Practice Address - Street 1:724 S CEDAR RIDGE DR
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-2204
Practice Address - Country:US
Practice Address - Phone:310-686-8546
Practice Address - Fax:214-467-5268
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22921122300000X
CA52537122300000X
OK4475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist