Provider Demographics
NPI:1902937782
Name:BROMAGHIM, ROGER JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:JOSEPH
Last Name:BROMAGHIM
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 1:16991 198TH AVENUE NW
Mailing Address - Street 2:PO BOX 249
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-0249
Mailing Address - Country:US
Mailing Address - Phone:763-263-6350
Mailing Address - Fax:763-263-0136
Practice Address - Street 1:16991 198TH AVENUE NW
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-0249
Practice Address - Country:US
Practice Address - Phone:763-263-6350
Practice Address - Fax:763-263-0136
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND93551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND9355OtherSTATE LICENSE