Healthcare Provider Details

I. General information

NPI: 1265752638
Provider Name (Legal Business Name): SARA R ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 FAIRFIELD HILL ROAD
BLOOMFIELD KY
40008-0484
US

IV. Provider business mailing address

PO BOX 484 112 FAIRFIELD HILL ROAD
BLOOMFIELD KY
40008-0484
US

V. Phone/Fax

Practice location:
  • Phone: 502-252-0056
  • Fax: 502-252-0058
Mailing address:
  • Phone: 502-252-0056
  • Fax: 502-252-0058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8867
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8867
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: