Provider Demographics
NPI:1861564817
Name:ROGER WIRTZ DMD PA
Entity type:Organization
Organization Name:ROGER WIRTZ DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:STEPHENSON
Authorized Official - Last Name:WIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-982-5349
Mailing Address - Street 1:1765 LELIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4820
Mailing Address - Country:US
Mailing Address - Phone:601-982-5349
Mailing Address - Fax:601-982-9084
Practice Address - Street 1:1765 LELIA DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4820
Practice Address - Country:US
Practice Address - Phone:601-982-5349
Practice Address - Fax:601-982-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS204083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty