Provider Demographics
NPI:1740274661
Name:VERGOTINE, RODNEY J (DDS-PEDIATRIC)
Entity type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:J
Last Name:VERGOTINE
Suffix:
Gender:M
Credentials:DDS-PEDIATRIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1078
Mailing Address - Country:US
Mailing Address - Phone:734-764-8451
Mailing Address - Fax:
Practice Address - Street 1:1011 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:734-764-8451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5438-0151223P0221X
IL0190244281223P0221X
MI29010229541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019024428Medicaid