Provider Demographics
NPI:1164482873
Name:HOGAN, TIMOTHY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
Last Name:HOGAN
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 1:8267 COLLEGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919
Mailing Address - Country:US
Mailing Address - Phone:239-938-3060
Mailing Address - Fax:239-936-1139
Practice Address - Street 1:8267 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5193
Practice Address - Country:US
Practice Address - Phone:239-936-8151
Practice Address - Fax:239-936-1954
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN112831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL67638Medicare ID - Type Unspecified
FLT54935Medicare UPIN
FL40442Medicare ID - Type UnspecifiedGROUP NUMBER