Provider Demographics
NPI:1548551435
Name:ROGERS, JACOB H (DDS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:H
Last Name:ROGERS
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 1:6521 PARADISE BLVD NW STE M
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-6199
Mailing Address - Country:US
Mailing Address - Phone:505-350-3786
Mailing Address - Fax:
Practice Address - Street 1:6521 PARADISE BLVD NW STE M
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-6199
Practice Address - Country:US
Practice Address - Phone:505-890-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMDD36451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program