Provider Demographics
NPI:1194463778
Name:RODGERS, JAKOB (DDS)
Entity type:Individual
Prefix:
First Name:JAKOB
Middle Name:
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 1:12190 W EVELY PINES LN
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-6126
Mailing Address - Country:US
Mailing Address - Phone:208-996-3003
Mailing Address - Fax:
Practice Address - Street 1:12190 W EVELY PINES LN
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-6126
Practice Address - Country:US
Practice Address - Phone:208-996-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2024-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist