Provider Demographics
NPI:1659343044
Name:ROGERS, KATHLEEN A (DMD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:ROGERS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 GUSDORF RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5206
Mailing Address - Country:US
Mailing Address - Phone:505-751-9333
Mailing Address - Fax:505-737-0483
Practice Address - Street 1:1335 GUSDORF RD
Practice Address - Street 2:SUITE A
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5204
Practice Address - Country:US
Practice Address - Phone:505-751-9333
Practice Address - Fax:505-737-0483
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD18231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09258566Medicaid
NMA9017Medicaid