Provider Demographics
NPI:1356576284
Name:BOGERT, MERREDITH COLMAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MERREDITH
Middle Name:COLMAN
Last Name:BOGERT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3223 N BROAD ST
Mailing Address - Street 2:TEMPLE UNIVERSITY SCHOOL OF DENTISTRY - ROOM 2E05
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5007
Mailing Address - Country:US
Mailing Address - Phone:215-707-5934
Mailing Address - Fax:215-707-2840
Practice Address - Street 1:3223 N BROAD ST
Practice Address - Street 2:TEMPLE UNIVERSITY SCHOOL OF DENTISTRY - ROOM 2E05
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-5934
Practice Address - Fax:215-707-2840
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-023983-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS-023983-LOtherDENTAL LICENSE
PABB2699227OtherDEA NUMBER