Provider Demographics
NPI:1548489818
Name:ROGERS, CLINT A (DMD)
Entity type:Individual
Prefix:DR
First Name:CLINT
Middle Name:A
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 1:2377 SW COUNTY ROAD 360A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-8414
Mailing Address - Country:US
Mailing Address - Phone:850-973-6621
Mailing Address - Fax:850-973-6672
Practice Address - Street 1:189 SW CAPTAIN BROWN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-4351
Practice Address - Country:US
Practice Address - Phone:850-973-6621
Practice Address - Fax:850-973-6672
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN152321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070387700Medicaid