=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811214307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROGER L. STUART
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2010
-----------------------------------------------------
Last Update Date | 04/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14313 NE 20TH AVE SUITE A-101
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98686-1487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-574-3985
-----------------------------------------------------
Fax | 360-574-0452
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14313 NE 20TH AVE SUITE A-101
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98686-1487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-574-3985
-----------------------------------------------------
Fax | 360-574-0452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. ROGER LELAND STUART
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 360-574-3985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4261
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------