Provider Demographics
NPI:1003247495
Name:VOGT, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VOGT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 GEIGER RD
Mailing Address - Street 2:
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-9048
Mailing Address - Country:US
Mailing Address - Phone:585-455-7673
Mailing Address - Fax:
Practice Address - Street 1:747 GEIGER RD
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9048
Practice Address - Country:US
Practice Address - Phone:585-455-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022823-1124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist