Provider Demographics
NPI:1770693715
Name:RODGERS, TIMOTHY JOHN (DDS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:RODGERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HIGHWAY 146 S
Mailing Address - Street 2:SUITE 255
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77571-6131
Mailing Address - Country:US
Mailing Address - Phone:281-471-3066
Mailing Address - Fax:281-471-8492
Practice Address - Street 1:1200 HIGHWAY 146 S
Practice Address - Street 2:SUITE 255
Practice Address - City:LA PORTE
Practice Address - State:TX
Practice Address - Zip Code:77571-6131
Practice Address - Country:US
Practice Address - Phone:281-471-3066
Practice Address - Fax:281-471-8492
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice