Provider Demographics
NPI:1700135407
Name:JOHN ROGERS DDS PC
Entity Type:Organization
Organization Name:JOHN ROGERS DDS PC
Other - Org Name:REFRESH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-408-9543
Mailing Address - Street 1:6802 S OLYMPIA AVE
Mailing Address - Street 2:SUITE 275
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-1823
Mailing Address - Country:US
Mailing Address - Phone:918-408-9543
Mailing Address - Fax:
Practice Address - Street 1:6802 S OLYMPIA AVE
Practice Address - Street 2:SUITE 275
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1823
Practice Address - Country:US
Practice Address - Phone:918-408-9543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK62091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200297330AMedicaid