Provider Demographics
NPI:1073532727
Name:IVEY, ROGER THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:THOMAS
Last Name:IVEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 GRAPE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-3965
Mailing Address - Country:US
Mailing Address - Phone:407-343-2003
Mailing Address - Fax:407-892-6468
Practice Address - Street 1:1875 BOGGY CREEK RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4428
Practice Address - Country:US
Practice Address - Phone:407-343-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN174041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN17404OtherFLORIDA STATE LICENSE