Healthcare Provider Details

I. General information

NPI: 1023792058
Provider Name (Legal Business Name): ROGER SALAZAR DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 W 21ST ST
CHICAGO IL
60608-4511
US

IV. Provider business mailing address

901 S ASHLAND AVE APT 214
CHICAGO IL
60607-4082
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax:
Mailing address:
  • Phone: 480-277-6236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number019.034362
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: