Provider Demographics
NPI:1104205905
Name:JONATHAN RYAN ROGENMOSER DDS LLC
Entity Type:Organization
Organization Name:JONATHAN RYAN ROGENMOSER DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:ROGENMOSER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-445-0667
Mailing Address - Street 1:2994 MESSINA RD
Mailing Address - Street 2:
Mailing Address - City:BOYCE
Mailing Address - State:LA
Mailing Address - Zip Code:71409-9262
Mailing Address - Country:US
Mailing Address - Phone:318-445-0667
Mailing Address - Fax:
Practice Address - Street 1:160 WINDERMERE BOULEVARD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303
Practice Address - Country:US
Practice Address - Phone:318-445-0667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6442261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental