Basic Information
| Provider Information | |||||||||
| NPI: | 1699921429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 36TH ST | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982256540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607460946 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989013020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094544143 | ||||||||
| FaxNumber: | 5094543651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 11/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60035251 | WA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 5057492 | 05 | WA | MEDICAID |