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General NPI Number Information
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NPI Number | 1457525263
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Entity Type | Individual
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Provider Name | PETER JAMES ROUKEMA D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/14/2008
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Last Update Date | 02/04/2022
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Provider Practice Location Address
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Address Line | 228 VILLAGE DR
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City | PAGOSA SPRINGS
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State | CO
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Zip | 81147-8308
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Country | US
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Telephone | 970-731-2126
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Fax |
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Provider Business Mailing Address
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Address Line | 115 HAREBELL DR
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City | PAGOSA SPRINGS
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State | CO
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Zip | 81147-7721
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Country | US
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Telephone | 216-374-5693
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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 | DD3069
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 10054
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License Number State | CO
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