Provider Demographics
NPI:1922082486
Name:KENNETH B ROGERS DMD PA
Entity Type:Organization
Organization Name:KENNETH B ROGERS DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BENJAMINE
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:863-293-0636
Mailing Address - Street 1:1550 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4306
Mailing Address - Country:US
Mailing Address - Phone:863-293-0636
Mailing Address - Fax:863-293-2479
Practice Address - Street 1:1550 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4306
Practice Address - Country:US
Practice Address - Phone:863-293-0636
Practice Address - Fax:863-293-2479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN115151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty