Provider Demographics
NPI:1104806389
Name:BLACK, ROGER WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WILLIAM
Last Name:BLACK
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 1:28969 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0916
Mailing Address - Country:US
Mailing Address - Phone:248-398-5545
Mailing Address - Fax:248-398-6153
Practice Address - Street 1:28969 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0916
Practice Address - Country:US
Practice Address - Phone:248-398-5545
Practice Address - Fax:248-398-6153
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist