Provider Demographics
NPI:1811171226
Name:GORDON K. ROEDIGER, D.D.S., EASTSIDE, P.C.
Entity type:Organization
Organization Name:GORDON K. ROEDIGER, D.D.S., EASTSIDE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:ROEDIGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-795-3773
Mailing Address - Street 1:5190 E FARNESS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2142
Mailing Address - Country:US
Mailing Address - Phone:520-795-3773
Mailing Address - Fax:520-795-4008
Practice Address - Street 1:5190 E FARNESS DR STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2142
Practice Address - Country:US
Practice Address - Phone:520-795-3773
Practice Address - Fax:520-795-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2385122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1457543613OtherNPI
AZ1093925232OtherNPI
AZ1669532057OtherNPI