Provider Demographics
NPI:1447419080
Name:BROOKS, JR, ROGER DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DALE
Last Name:BROOKS, JR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-4103
Mailing Address - Country:US
Mailing Address - Phone:479-890-6174
Mailing Address - Fax:479-967-0339
Practice Address - Street 1:402 E PARKWAY DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-4103
Practice Address - Country:US
Practice Address - Phone:479-890-6174
Practice Address - Fax:479-967-0339
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR36671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice