Provider Demographics
NPI:1265687552
Name:BOGAN, DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BOGAN
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 1:1924D DAUPHIN ISLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36605-3004
Mailing Address - Country:US
Mailing Address - Phone:251-478-1183
Mailing Address - Fax:251-478-1125
Practice Address - Street 1:1924D DAUPHIN ISLAND PKWY
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36605-3004
Practice Address - Country:US
Practice Address - Phone:251-478-1183
Practice Address - Fax:251-478-1125
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL011460122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist