Provider Demographics
NPI:1114535184
Name:ROGERS, TAYLOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:
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 1:1360 N LAKE SHORE DR APT 915
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8455
Mailing Address - Country:US
Mailing Address - Phone:317-385-8448
Mailing Address - Fax:
Practice Address - Street 1:4039 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-5219
Practice Address - Country:US
Practice Address - Phone:773-782-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032789122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist