=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396932745
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OWEN JAN ROGAL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501-7 SOUTH 12TH STREET
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19147-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-545-2100
-----------------------------------------------------
Fax | 215-923-1012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501-507 SOUTH 12TH STREET
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19147-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-545-2100
-----------------------------------------------------
Fax | 215-923-1012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | DS016039L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------