Provider Demographics
NPI:1184771917
Name:BOGUE, CHRISTOPHER W (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:W
Last Name:BOGUE
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 1:703 SIMON AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-2264
Mailing Address - Country:US
Mailing Address - Phone:712-792-4375
Mailing Address - Fax:712-792-3371
Practice Address - Street 1:703 SIMON AVE
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-2264
Practice Address - Country:US
Practice Address - Phone:712-792-4375
Practice Address - Fax:712-792-3371
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1264721Medicaid
IA49002OtherBLUECROSS BLUESHIELD ID #
IA180751OtherUNITED CONCORDIA ID #