Provider Demographics
NPI:1114991635
Name:BOGDON, KEVIN M (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:BOGDON
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 1:523 E GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-2015
Mailing Address - Country:US
Mailing Address - Phone:818-243-5227
Mailing Address - Fax:
Practice Address - Street 1:523 E GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91207-2015
Practice Address - Country:US
Practice Address - Phone:818-243-5227
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice