Provider Demographics
NPI:1558325878
Name:BOGARDUS, AMY JANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:JANE
Last Name:BOGARDUS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2007
Mailing Address - Country:US
Mailing Address - Phone:859-236-1130
Mailing Address - Fax:859-239-9384
Practice Address - Street 1:400 S 4TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2007
Practice Address - Country:US
Practice Address - Phone:859-236-1130
Practice Address - Fax:859-239-9384
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6874174400000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64026313Medicaid
KY60068749Medicaid
KY0201304Medicare ID - Type Unspecified
KYU70781Medicare UPIN