Healthcare Provider Details

I. General information

NPI: 1164593034
Provider Name (Legal Business Name): ROGER D PLOOSTER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 S 48TH ST
LINCOLN NE
68510-3726
US

IV. Provider business mailing address

827 S 48TH ST
LINCOLN NE
68510-3726
US

V. Phone/Fax

Practice location:
  • Phone: 402-486-0825
  • Fax: 402-486-4935
Mailing address:
  • Phone: 402-486-0825
  • Fax: 402-486-4935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4733
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: