=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649455379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GORDON K. ROEDIGER, D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2007
-----------------------------------------------------
Last Update Date | 12/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6127 N LA CHOLLA BLVD STE 175
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85741-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-575-6216
-----------------------------------------------------
Fax | 520-575-6219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6127 N LA CHOLLA BLVD STE 175
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85741-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-575-6216
-----------------------------------------------------
Fax | 520-575-6219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. GORDON KENT ROEDIGER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 520-575-6216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2385
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------