Healthcare Provider Details

I. General information

NPI: 1770638124
Provider Name (Legal Business Name): DEAN EDWARDS ROLLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-6460
  • Fax:
Mailing address:
  • Phone: 801-442-4950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number5375604-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: