Provider Demographics
NPI:1710010863
Name:BOUGGY, ROBERT CLIFFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CLIFFORD
Last Name:BOUGGY
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 1:1827 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE BRA
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2279
Mailing Address - Country:US
Mailing Address - Phone:765-463-5561
Mailing Address - Fax:
Practice Address - Street 1:1827 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE BRA
Practice Address - State:IN
Practice Address - Zip Code:47906-2279
Practice Address - Country:US
Practice Address - Phone:765-463-5561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008204B1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice