Provider Demographics
NPI:1194982405
Name:GORODESKY, ROMAN (DDS)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:GORODESKY
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 1:7101 N GREEN BAY AVE
Mailing Address - Street 2:STE 10
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2800
Mailing Address - Country:US
Mailing Address - Phone:414-351-0510
Mailing Address - Fax:414-351-1440
Practice Address - Street 1:7101 N GREEN BAY AVE
Practice Address - Street 2:STE 10
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-2265
Practice Address - Country:US
Practice Address - Phone:414-351-0510
Practice Address - Fax:414-351-1440
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5302122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist