Provider Demographics
NPI:1720131758
Name:ROGERS, JOHN CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:ROGERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ROGERS
Other - Middle Name:
Other - Last Name:DENTAL,
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:INC
Mailing Address - Street 1:10522 S CICERO AVE
Mailing Address - Street 2:SUITE 404
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5200
Mailing Address - Country:US
Mailing Address - Phone:708-422-7733
Mailing Address - Fax:
Practice Address - Street 1:10522 S CICERO AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5200
Practice Address - Country:US
Practice Address - Phone:708-422-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018-0190461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice