Provider Demographics
NPI:1740925916
Name:BOGALE, ELIAS (DDS)
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:
Last Name:BOGALE
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 1:645 CLASSIC CT
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:645 CLASSIC CT
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8670
Practice Address - Country:US
Practice Address - Phone:321-253-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043979122300000X
FLDN278081223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice