Provider Demographics
NPI:1093740433
Name:COGHLAN, JOHN KEVIN (DDS, MSD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KEVIN
Last Name:COGHLAN
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 E COVENANTER DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6320
Mailing Address - Country:US
Mailing Address - Phone:812-332-9296
Mailing Address - Fax:
Practice Address - Street 1:2911 E COVENANTER DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6320
Practice Address - Country:US
Practice Address - Phone:812-332-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008895A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics