Provider Demographics
NPI:1689370892
Name:BOGOTTY, DYLAN JORDAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:JORDAN
Last Name:BOGOTTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 58TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2821
Mailing Address - Country:US
Mailing Address - Phone:701-213-0726
Mailing Address - Fax:
Practice Address - Street 1:4825 58TH AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-2821
Practice Address - Country:US
Practice Address - Phone:701-213-0726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician