Provider Demographics
NPI:1720430325
Name:ROGERS, THEODORA (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TEDDY
Other - Middle Name:KK
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:505 PREAKNESS DR
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-8472
Mailing Address - Country:US
Mailing Address - Phone:816-572-1973
Mailing Address - Fax:
Practice Address - Street 1:1000 BLUFF ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-2321
Practice Address - Country:US
Practice Address - Phone:573-642-7234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016020286122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist