Provider Demographics
NPI:1356824205
Name:FOGG, MAGGIE ROSE (RDH)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:ROSE
Last Name:FOGG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 STARLIGHT LN
Mailing Address - Street 2:
Mailing Address - City:EASTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02642-3022
Mailing Address - Country:US
Mailing Address - Phone:508-246-4466
Mailing Address - Fax:
Practice Address - Street 1:49 HARRY KEMP WAY
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1618
Practice Address - Country:US
Practice Address - Phone:508-487-9395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH89077124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist