Basic Information
| Provider Information | |||||||||
| NPI: | 1629616636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | KIANA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4855 FRAZEE RD APT 814 | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920576835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4435205301 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS | ||||||||
| Address2: | BLDG H 2005 KNIGHT LANE | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322120140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2019 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 32556 | CA | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 32556 | 01 | CA | CALIFORNIA DENTAL HYGIENE LICENSE NUMBER | OTHER |