Provider Demographics
NPI:1912006586
Name:RODGERS, GARY A (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:RODGERS
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 1:433 N BOLINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-3704
Mailing Address - Country:US
Mailing Address - Phone:630-759-4191
Mailing Address - Fax:
Practice Address - Street 1:433 N BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3704
Practice Address - Country:US
Practice Address - Phone:630-759-4191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist