Provider Demographics
NPI:1922167139
Name:BOGUE, JOHN PHILLIP SR (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:BOGUE
Suffix:SR
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 1:9165 SOUTH RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-9700
Mailing Address - Country:US
Mailing Address - Phone:419-878-7332
Mailing Address - Fax:
Practice Address - Street 1:5950 AIRPORT HIGHWAY SUITE 10
Practice Address - Street 2:
Practice Address - City:TOLDEO
Practice Address - State:OH
Practice Address - Zip Code:43615
Practice Address - Country:US
Practice Address - Phone:419-867-9839
Practice Address - Fax:419-867-6996
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300198691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics