Provider Demographics
NPI:1750506465
Name:BOGGAN, BRANDON
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:BOGGAN
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 1:2705 PELHAM PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124
Mailing Address - Country:US
Mailing Address - Phone:205-664-4140
Mailing Address - Fax:205-664-3234
Practice Address - Street 1:2705 PELHAM PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124
Practice Address - Country:US
Practice Address - Phone:205-664-4140
Practice Address - Fax:205-664-3234
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL46841223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics