Provider Demographics
NPI:1508255803
Name:BOGE, EMILY J I (RDH BS MPA)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:J
Last Name:BOGE
Suffix:I
Gender:F
Credentials:RDH BS MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13151 KRAMER RD
Mailing Address - Street 2:
Mailing Address - City:FARLEY
Mailing Address - State:IA
Mailing Address - Zip Code:52046-8439
Mailing Address - Country:US
Mailing Address - Phone:319-231-1193
Mailing Address - Fax:
Practice Address - Street 1:120 E FAYETTE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1705
Practice Address - Country:US
Practice Address - Phone:319-231-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-10
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03116124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist