Provider Demographics
NPI:1609056878
Name:MOGANNAM, JIRIES PETER (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JIRIES
Middle Name:PETER
Last Name:MOGANNAM
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 SONOMA AVE
Mailing Address - Street 2:SUITE #220
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4819
Mailing Address - Country:US
Mailing Address - Phone:707-566-7300
Mailing Address - Fax:
Practice Address - Street 1:1111 SONOMA AVE
Practice Address - Street 2:SUITE #220
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4819
Practice Address - Country:US
Practice Address - Phone:707-566-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA601911223S0112X
CAA114965204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery