Provider Demographics
NPI:1295051720
Name:ROGER L. GILLESPIE, D.D.S., INC.
Entity type:Organization
Organization Name:ROGER L. GILLESPIE, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-325-4155
Mailing Address - Street 1:23560 MADISON ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4708
Mailing Address - Country:US
Mailing Address - Phone:310-325-4155
Mailing Address - Fax:
Practice Address - Street 1:23560 MADISON ST
Practice Address - Street 2:SUITE 215
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4708
Practice Address - Country:US
Practice Address - Phone:310-325-4155
Practice Address - Fax:310-325-7368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32080122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty