Provider Demographics
NPI:1265752638
Name:ROGERS, SARA R
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:R
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 484
Mailing Address - Street 2:112 FAIRFIELD HILL ROAD
Mailing Address - City:BLOOMFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40008-0484
Mailing Address - Country:US
Mailing Address - Phone:502-252-0056
Mailing Address - Fax:502-252-0058
Practice Address - Street 1:112 FAIRFIELD HILL ROAD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:KY
Practice Address - Zip Code:40008-0484
Practice Address - Country:US
Practice Address - Phone:502-252-0056
Practice Address - Fax:502-252-0058
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8867122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100139410Medicaid