Provider Demographics
NPI:1982769964
Name:MUELLER, ROGER MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:MICHAEL
Last Name:MUELLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 HUNTERS RDG
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3061
Mailing Address - Country:US
Mailing Address - Phone:618-659-3543
Mailing Address - Fax:
Practice Address - Street 1:3716 PONTOON RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4252
Practice Address - Country:US
Practice Address - Phone:618-931-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice