Active NPI
Glenn Stephen Roeder, D.D.S.
- Periodontics
- Glendale, CA
National Provider Identifier
1164572939
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 30624
- Practice address
- 230 N Maryland Ave
Glendale, CA 91206-4261 - Phone
- (310) 739-5579
- NPI assigned
- Jan 11, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 30624 | CA | Primary |
Addresses
Primary practice location
230 N Maryland Ave
Glendale, CA 91206-4261
Mailing address
PO Box 67827
Los Angeles, CA 90067-2806
Phone (310) 739-5579
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180904000109 | CA | Order and Referring Only - Dentist | 2860742418 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 30624 | CA | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168473600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1238544000000",
"number": "1164572939",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 67827",
"city": "LOS ANGELES",
"state": "CA",
"postal_code": "900672806",
"telephone_number": "310-739-5579"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "230 N MARYLAND AVE",
"city": "GLENDALE",
"state": "CA",
"postal_code": "912064261",
"telephone_number": "310-739-5579"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROEDER",
"first_name": "GLENN",
"middle_name": "STEPHEN",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-01-11",
"last_updated": "2009-04-01",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "CA",
"license": "30624",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Glendale, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.