Provider Demographics
NPI:1225174287
Name:BOGARD, LOUIS E (DDS)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:E
Last Name:BOGARD
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:PO BOX 670
Mailing Address - Street 2:10825 OLD HWY 64
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008
Mailing Address - Country:US
Mailing Address - Phone:731-658-5291
Mailing Address - Fax:731-658-6536
Practice Address - Street 1:10825 OLD HWY 64
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008
Practice Address - Country:US
Practice Address - Phone:731-658-5291
Practice Address - Fax:731-658-6536
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000006956122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNS440640Medicaid
9179020OtherDORAL DENTAL