Provider Demographics
NPI:1386961233
Name:KILCOYNE, ROGER DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DALE
Last Name:KILCOYNE
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 1:364 GARLAND ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-7129
Mailing Address - Country:US
Mailing Address - Phone:901-574-2402
Mailing Address - Fax:
Practice Address - Street 1:364 GARLAND ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7129
Practice Address - Country:US
Practice Address - Phone:901-574-2402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO101591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice