Provider Demographics
NPI:1497829063
Name:PAUL, ROGER LOUIS (DMD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LOUIS
Last Name:PAUL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 W LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-6020
Mailing Address - Country:US
Mailing Address - Phone:309-682-0770
Mailing Address - Fax:309-682-7285
Practice Address - Street 1:521 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-6020
Practice Address - Country:US
Practice Address - Phone:309-682-0770
Practice Address - Fax:309-682-7285
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19164231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice