Healthcare Provider Details

I. General information

NPI: 1265558795
Provider Name (Legal Business Name): THOMAS PAUL ROEDER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 THE ALAMEDA
BERKELEY CA
94707-2308
US

IV. Provider business mailing address

98 DEER PARK AVE
SAN RAFAEL CA
94901-2312
US

V. Phone/Fax

Practice location:
  • Phone: 510-526-1411
  • Fax:
Mailing address:
  • Phone: 415-453-0484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number20448
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: