Provider Demographics
NPI:1720438716
Name:BOGOPANE, BOKANG (DDS)
Entity Type:Individual
Prefix:
First Name:BOKANG
Middle Name:
Last Name:BOGOPANE
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 1:9401 COORS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4007
Mailing Address - Country:US
Mailing Address - Phone:505-890-2773
Mailing Address - Fax:505-898-3022
Practice Address - Street 1:9401 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4007
Practice Address - Country:US
Practice Address - Phone:505-890-2773
Practice Address - Fax:505-898-3022
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA66951223G0001X
NMDD4525122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice