Healthcare Provider Details

I. General information

NPI: 1962548297
Provider Name (Legal Business Name): ROGER THOMAS BROWN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 MAGNOLIA ST.
ORANGEBURG SC
29115-1466
US

IV. Provider business mailing address

3310 MAGNOLIA ST.
ORANGEBURG SC
29115-1466
US

V. Phone/Fax

Practice location:
  • Phone: 803-531-6900
  • Fax:
Mailing address:
  • Phone: 803-531-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number47828
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6137
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number4276
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: