Provider Demographics
NPI:1508908906
Name:ROGERS, LORI LOUISE (DDS)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LOUISE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11246 MONTAUBON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131
Mailing Address - Country:US
Mailing Address - Phone:858-549-4356
Mailing Address - Fax:
Practice Address - Street 1:3855 AVACADO BLVD
Practice Address - Street 2:#260
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941
Practice Address - Country:US
Practice Address - Phone:619-670-1706
Practice Address - Fax:619-670-1860
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39073122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist