Provider Demographics
NPI:1881791937
Name:ROGER H BOHANNAN DDS INC
Entity type:Organization
Organization Name:ROGER H BOHANNAN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:BOHANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-282-6751
Mailing Address - Street 1:1404 BROWN TRAIL
Mailing Address - Street 2:SUITE E
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6417
Mailing Address - Country:US
Mailing Address - Phone:817-282-6751
Mailing Address - Fax:
Practice Address - Street 1:1404 BROWN TRAIL
Practice Address - Street 2:SUITE E
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6417
Practice Address - Country:US
Practice Address - Phone:817-282-6751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty