Provider Demographics
NPI:1538264395
Name:MATHIS, ROGER SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:SCOTT
Last Name:MATHIS
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 1:444 PROMENADE DR
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-8666
Mailing Address - Country:US
Mailing Address - Phone:940-453-6778
Mailing Address - Fax:
Practice Address - Street 1:444 PROMENADE DR
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-8666
Practice Address - Country:US
Practice Address - Phone:940-453-6778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15806122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD15806OtherDELTA DENTAL