Provider Demographics
NPI:1043630197
Name:KOGAN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8278 BANPO BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-0031
Mailing Address - Country:US
Mailing Address - Phone:201-406-6596
Mailing Address - Fax:
Practice Address - Street 1:3027 FOREST HILL BLVD STE A3
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5934
Practice Address - Country:US
Practice Address - Phone:561-459-1488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02581400122300000X
390200000X
FLDN248431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program