Provider Demographics
NPI:1962035261
Name:ICBOGGAN, INC
Entity Type:Organization
Organization Name:ICBOGGAN, INC
Other - Org Name:OROFACIAL FITNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RDH
Authorized Official - Prefix:
Authorized Official - First Name:NERISSA
Authorized Official - Middle Name:T
Authorized Official - Last Name:BOGGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:925-962-7450
Mailing Address - Street 1:3799 MT DIABLO BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3545
Mailing Address - Country:US
Mailing Address - Phone:925-962-7450
Mailing Address - Fax:
Practice Address - Street 1:3799 MT DIABLO BLVD UNIT 200
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3545
Practice Address - Country:US
Practice Address - Phone:925-962-7450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-15
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty