Provider Demographics
NPI:1497409411
Name:KOGA ORTHODONTICS LLC
Entity type:Organization
Organization Name:KOGA ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISEANE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOGA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS/MSD
Authorized Official - Phone:269-985-8168
Mailing Address - Street 1:2124 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3611
Mailing Address - Country:US
Mailing Address - Phone:318-388-4209
Mailing Address - Fax:
Practice Address - Street 1:2124 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3611
Practice Address - Country:US
Practice Address - Phone:318-388-4209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty