Provider Demographics
NPI:1972944130
Name:ROGERS, BLAKE R (DMD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:R
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 1:41 WORCESTER SQ
Mailing Address - Street 2:APT 6
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2919
Mailing Address - Country:US
Mailing Address - Phone:509-868-4225
Mailing Address - Fax:
Practice Address - Street 1:41 WORCESTER SQ
Practice Address - Street 2:APT 6
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2919
Practice Address - Country:US
Practice Address - Phone:509-868-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18572061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program