Provider Demographics
NPI:1407926413
Name:HOGAN, RACHAEL R (DDS)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:R
Last Name:HOGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:
Other - Last Name:ROSENFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:17395 RESERVATION RD
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0332
Mailing Address - Country:US
Mailing Address - Phone:360-466-3900
Mailing Address - Fax:360-466-7301
Practice Address - Street 1:17395 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8802
Practice Address - Country:US
Practice Address - Phone:360-466-3900
Practice Address - Fax:360-466-7301
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000093381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0174706OtherLABOR AND INDUSTRIES
WA5044490Medicaid