Provider Demographics
NPI:1780710046
Name:BERMINGHAM, ROGER P (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:P
Last Name:BERMINGHAM
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 1:600 HOUZE WAY
Mailing Address - Street 2:SUITE B1
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076
Mailing Address - Country:US
Mailing Address - Phone:770-587-4296
Mailing Address - Fax:770-587-0161
Practice Address - Street 1:600 HOUZE WAY
Practice Address - Street 2:SUITE B1
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:770-587-4296
Practice Address - Fax:770-587-0161
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist