Provider Demographics
NPI:1790842417
Name:ROGERS, TERRI LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
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 1:6820 LA TIJERA BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1931
Mailing Address - Country:US
Mailing Address - Phone:310-670-2200
Mailing Address - Fax:310-670-3189
Practice Address - Street 1:6820 LA TIJERA BLVD STE 205
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1931
Practice Address - Country:US
Practice Address - Phone:310-670-2200
Practice Address - Fax:310-670-3189
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA375991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
671459OtherUNITED CONCORDIA