Provider Demographics
NPI:1104010255
Name:HOGAN, MICHAEL BRUCE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRUCE
Last Name:HOGAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CECIL ST STE G
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-7066
Mailing Address - Country:US
Mailing Address - Phone:573-317-1473
Mailing Address - Fax:
Practice Address - Street 1:108 CECIL ST STE G
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-7066
Practice Address - Country:US
Practice Address - Phone:573-317-1473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0120091223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health