Provider Demographics
NPI:1164089629
Name:OGLE, KEVIN SAMUEL ROHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SAMUEL ROHAN
Last Name:OGLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8310
Mailing Address - Country:US
Mailing Address - Phone:386-481-6886
Mailing Address - Fax:
Practice Address - Street 1:2777 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8310
Practice Address - Country:US
Practice Address - Phone:386-481-6886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10253390200000X
FLDN255291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program