Healthcare Provider Details

I. General information

NPI: 1174598916
Provider Name (Legal Business Name): PAUL KOGAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 E BELL RD SUITE 111
PHOENIX AZ
85022-6639
US

IV. Provider business mailing address

702 E BELL RD SUITE 111
PHOENIX AZ
85022-6639
US

V. Phone/Fax

Practice location:
  • Phone: 602-404-3800
  • Fax: 602-404-8757
Mailing address:
  • Phone: 602-482-7000
  • Fax: 602-482-7021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD6524
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: