Provider Demographics
NPI:1770010043
Name:BOGLE, SAMANTHA R (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:R
Last Name:BOGLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 STUART CT
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9615
Mailing Address - Country:US
Mailing Address - Phone:973-943-9514
Mailing Address - Fax:
Practice Address - Street 1:495 MAIN ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:MA
Practice Address - Zip Code:01450-4253
Practice Address - Country:US
Practice Address - Phone:978-449-9919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02632900122300000X
MADN18579161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist