Healthcare Provider Details

I. General information

NPI: 1588962781
Provider Name (Legal Business Name): WILLIAM J BOGGESS D.M.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 UNIVERSITY DR S
FARGO ND
58103-4939
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-417-4640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2398
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number16610
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: