Provider Demographics
NPI:1457525263
Name:ROUKEMA, PETER JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JAMES
Last Name:ROUKEMA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 HAREBELL DR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-7721
Mailing Address - Country:US
Mailing Address - Phone:216-374-5693
Mailing Address - Fax:
Practice Address - Street 1:228 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8308
Practice Address - Country:US
Practice Address - Phone:970-731-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3069122300000X
CO100541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist