Healthcare Provider Details

I. General information

NPI: 1417052820
Provider Name (Legal Business Name): ROGER SCOTT THOMPSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL AMERICANO BASE NAVAL DE ROTA APARTADO DE CORREOS 33
ROTA CADIZ
11530
ES

IV. Provider business mailing address

PSC 819 BOX 18
FPO AE
09645-0001
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-3524
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019.028888
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019028888
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5991
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: