Provider Demographics
NPI:1376721340
Name:ROG, MARIUS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIUS
Middle Name:
Last Name:ROG
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 1:5408 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1225
Mailing Address - Country:US
Mailing Address - Phone:773-774-9911
Mailing Address - Fax:773-355-5998
Practice Address - Street 1:5408 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1225
Practice Address - Country:US
Practice Address - Phone:773-774-9911
Practice Address - Fax:773-355-5998
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist