Provider Demographics
NPI:1700561636
Name:ROGAN, JACK LIAM (DMD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:LIAM
Last Name:ROGAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 FOREST DR APT 255
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-3174
Mailing Address - Country:US
Mailing Address - Phone:314-914-4227
Mailing Address - Fax:
Practice Address - Street 1:4500 STUART AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-5700
Practice Address - Country:US
Practice Address - Phone:803-751-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10510122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist