Provider Demographics
NPI:1265558795
Name:ROEDER, THOMAS PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PAUL
Last Name:ROEDER
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 1:98 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2312
Mailing Address - Country:US
Mailing Address - Phone:415-453-0484
Mailing Address - Fax:
Practice Address - Street 1:914 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2308
Practice Address - Country:US
Practice Address - Phone:510-526-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist