Provider Demographics
NPI:1952319832
Name:BOGNAR, MARK R (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:BOGNAR
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969-0249
Mailing Address - Country:US
Mailing Address - Phone:906-358-4587
Mailing Address - Fax:906-358-4118
Practice Address - Street 1:E 23970 POW WOW TRAIL RD
Practice Address - Street 2:LAC VIEUX DESERT HEALTH CENTER
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969-0249
Practice Address - Country:US
Practice Address - Phone:906-358-4587
Practice Address - Fax:906-358-4118
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3856015122300000X
MI2901019957122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33731100Medicaid
WI45575OtherSECURITY HEALTH PLAN