Healthcare Provider Details

I. General information

NPI: 1326133380
Provider Name (Legal Business Name): MICHAEL STEWART BOGGS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 NORTH BRYAN STREET
HICKSVILLE OH
43526
US

IV. Provider business mailing address

106 NORTH BRYAN STREET
HICKSVILLE OH
43526
US

V. Phone/Fax

Practice location:
  • Phone: 419-542-7748
  • Fax: 419-542-7748
Mailing address:
  • Phone: 419-542-7748
  • Fax: 419-542-7748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30016857
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12007974A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: