=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043630197
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK KOGAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2014
-----------------------------------------------------
Last Update Date | 10/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8752 ATLANTIC AVE
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33446-9814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-206-2973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8278 BANPO BRIDGE WAY
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33446-0031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-406-6596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02581400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN24843
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------