Healthcare Provider Details

I. General information

NPI: 1821078700
Provider Name (Legal Business Name): ROGER SATORU NISHIMURA JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 SW C AVE SUITE 102
LAWTON OK
73501-4300
US

IV. Provider business mailing address

311 NW RIDGEVIEW WAY
LAWTON OK
73505-6131
US

V. Phone/Fax

Practice location:
  • Phone: 580-248-6055
  • Fax: 580-248-6056
Mailing address:
  • Phone: 580-353-4372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberENDODONTICS # 27
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: