Healthcare Provider Details

I. General information

NPI: 1740259845
Provider Name (Legal Business Name): ROGER LEE CLOUSE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 WARREN SHARON RD
VIENNA OH
44473-9644
US

IV. Provider business mailing address

4400 WARREN SHARON RD
VIENNA OH
44473-9644
US

V. Phone/Fax

Practice location:
  • Phone: 330-394-1672
  • Fax: 330-394-1376
Mailing address:
  • Phone: 330-394-1672
  • Fax: 330-394-1376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.013257
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: