Provider Demographics
NPI:1467576835
Name:BOGAN, ROBERT ELLIOT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ELLIOT
Last Name:BOGAN
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 1:4 BASS POND DR
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1307
Mailing Address - Country:US
Mailing Address - Phone:516-484-8999
Mailing Address - Fax:
Practice Address - Street 1:5606 BROADWAY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5500
Practice Address - Country:US
Practice Address - Phone:718-549-5544
Practice Address - Fax:718-549-5544
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0454251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice