Provider Demographics
NPI:1609950872
Name:KOGAN, BORIS G (DDS)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:G
Last Name:KOGAN
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 1:1445 SHORE PKWY
Mailing Address - Street 2:APT.#6L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-6145
Mailing Address - Country:US
Mailing Address - Phone:917-837-5028
Mailing Address - Fax:
Practice Address - Street 1:1110 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE#3
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-9061
Practice Address - Country:US
Practice Address - Phone:718-649-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0466571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01682282Medicaid