Provider Demographics
NPI:1265879670
Name:MOGELL DENTAL ASSOCIATES
Entity type:Organization
Organization Name:MOGELL DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOGELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-394-9000
Mailing Address - Street 1:2900 N MILITARY TRL
Mailing Address - Street 2:STE 212
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6365
Mailing Address - Country:US
Mailing Address - Phone:561-394-9000
Mailing Address - Fax:561-488-1102
Practice Address - Street 1:2900 N MILITARY TRL
Practice Address - Street 2:STE 212
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6365
Practice Address - Country:US
Practice Address - Phone:561-394-9000
Practice Address - Fax:561-488-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12472337OtherCAQH