Provider Demographics
NPI:1720104698
Name:FLAKE, ROGER ALLEN (DDS)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALLEN
Last Name:FLAKE
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 1:13416 BOTHELL EVERETT HWY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5311
Mailing Address - Country:US
Mailing Address - Phone:425-338-2966
Mailing Address - Fax:425-338-3698
Practice Address - Street 1:13416 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 207
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-5311
Practice Address - Country:US
Practice Address - Phone:425-338-2966
Practice Address - Fax:425-338-3698
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
WA67011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice