Provider Demographics
NPI:1699921429
Name:ROGERS, RUSSELL WILLIAM (DMD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WILLIAM
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 1:224 36TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-6540
Mailing Address - Country:US
Mailing Address - Phone:360-746-0946
Mailing Address - Fax:
Practice Address - Street 1:12 S 8TH ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-3020
Practice Address - Country:US
Practice Address - Phone:509-454-4143
Practice Address - Fax:509-454-3651
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60035251122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5057492Medicaid