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General NPI Number Information
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NPI Number | 1134251523
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Entity Type | Individual
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Provider Name | ROGER T WETZEL DDS
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Gender | Male
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1421 PINE AVE
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City | RANTOUL
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State | IL
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Zip | 61866-2019
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Country | US
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Telephone | 217-892-2176
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Fax |
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Provider Business Mailing Address
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Address Line | 3007 WEEPING CHERRY DR
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City | CHAMPAIGN
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State | IL
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Zip | 61822-6880
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Country | US
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Telephone | 217-356-8925
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | IL
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