Provider Demographics
NPI:1700894300
Name:BADWAL, ROGER (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:BADWAL
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 NEWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4146
Mailing Address - Country:US
Mailing Address - Phone:203-797-0012
Mailing Address - Fax:203-797-0123
Practice Address - Street 1:107 NEWTOWN RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4146
Practice Address - Country:US
Practice Address - Phone:203-797-0012
Practice Address - Fax:203-797-0123
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0083871223S0112X
CT8387204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001364190Medicaid