Provider Demographics
NPI:1407007925
Name:ROGERS, JUSTIN L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:L
Last Name:ROGERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST DENTAL BATTALION
Mailing Address - Street 2:BOX 55521
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:760-725-5578
Mailing Address - Fax:
Practice Address - Street 1:1ST DENTAL BATTALION
Practice Address - Street 2:BOX 55521
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-5578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412232122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist