Provider Demographics
NPI:1295719417
Name:ROGER L FENDER DDS
Entity type:Organization
Organization Name:ROGER L FENDER DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LOREN
Authorized Official - Last Name:FENDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-524-3434
Mailing Address - Street 1:PO BOX 2496
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-6496
Mailing Address - Country:US
Mailing Address - Phone:816-524-3434
Mailing Address - Fax:816-524-3622
Practice Address - Street 1:519 SW 3RD ST
Practice Address - Street 2:SUITE G
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-2258
Practice Address - Country:US
Practice Address - Phone:816-524-3434
Practice Address - Fax:816-524-3622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO 14150122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty