Provider Demographics
NPI:1720313935
Name:ROGERS, RICHARD JASON (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JASON
Last Name:ROGERS
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:PO BOX 5737
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32540-5737
Mailing Address - Country:US
Mailing Address - Phone:850-650-5435
Mailing Address - Fax:850-654-1549
Practice Address - Street 1:4405 COMMONS DR E
Practice Address - Street 2:SUITE 201
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3457
Practice Address - Country:US
Practice Address - Phone:850-650-5435
Practice Address - Fax:850-654-1549
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00127821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice