Provider Demographics
NPI:1750595567
Name:RICHARD H. MOGENSEN DDS APC
Entity type:Organization
Organization Name:RICHARD H. MOGENSEN DDS APC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-452-5555
Mailing Address - Street 1:1624 FRANKLIN ST
Mailing Address - Street 2:SUITE 1206
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2824
Mailing Address - Country:US
Mailing Address - Phone:510-452-5555
Mailing Address - Fax:
Practice Address - Street 1:1624 FRANKLIN ST
Practice Address - Street 2:SUITE 1206
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2824
Practice Address - Country:US
Practice Address - Phone:510-452-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 21733122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92157-01Medicaid