Provider Demographics
NPI:1477046951
Name:FOGAL, JACQUELINE RENEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:RENEE
Last Name:FOGAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:RENEE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:225 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:PA
Mailing Address - Zip Code:17268-2169
Mailing Address - Country:US
Mailing Address - Phone:717-762-0605
Mailing Address - Fax:
Practice Address - Street 1:225 W 8TH ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:PA
Practice Address - Zip Code:17268
Practice Address - Country:US
Practice Address - Phone:717-762-0605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist