Healthcare Provider Details

I. General information

NPI: 1760465918
Provider Name (Legal Business Name): ELENA KOGAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 NORTHERN BLVD
GREAT NECK NY
11021-5306
US

IV. Provider business mailing address

130 SHORE RD
PORT WASHINGTON NY
11050-2205
US

V. Phone/Fax

Practice location:
  • Phone: 516-495-5469
  • Fax:
Mailing address:
  • Phone: 516-495-5469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number0491131
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: