Healthcare Provider Details

I. General information

NPI: 1659686202
Provider Name (Legal Business Name): RAFAEL A. ROGES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 S SEPULVEDA BLVD 1117
LOS ANGELES CA
90045-3807
US

IV. Provider business mailing address

8540 S SEPULVEDA BLVD 1117
LOS ANGELES CA
90045-3807
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-1388
  • Fax: 310-337-0678
Mailing address:
  • Phone: 310-337-1388
  • Fax: 310-337-0678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number31367
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: