Healthcare Provider Details

I. General information

NPI: 1346409125
Provider Name (Legal Business Name): ROGER C BROWN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 CAJON ST STE C
REDLANDS CA
92373
US

IV. Provider business mailing address

232 CAJON ST
REDLANDS CA
92373-5216
US

V. Phone/Fax

Practice location:
  • Phone: 909-792-1037
  • Fax: 909-793-3698
Mailing address:
  • Phone: 909-792-1037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number40917
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: