Provider Demographics
NPI:1174530869
Name:ABBOTT, ROGER W (DMD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:ABBOTT
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 1:290 HILDERBRAND DR NE
Mailing Address - Street 2:SUITE A-9
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3906
Mailing Address - Country:US
Mailing Address - Phone:404-255-2273
Mailing Address - Fax:404-467-4805
Practice Address - Street 1:290 HILDERBRAND DR NE
Practice Address - Street 2:SUITE A-9
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3906
Practice Address - Country:US
Practice Address - Phone:404-255-2273
Practice Address - Fax:404-467-4805
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0108671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice