Provider Demographics
NPI:1457976573
Name:FOGG, ANDREW JACOB (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JACOB
Last Name:FOGG
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 1:307 N PENNSYLVANIA ST APT 911
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-2311
Mailing Address - Country:US
Mailing Address - Phone:317-450-5364
Mailing Address - Fax:
Practice Address - Street 1:331 S STATE ROAD 135 STE D
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1453
Practice Address - Country:US
Practice Address - Phone:317-859-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013380A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice