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General NPI Number Information
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NPI Number | 1740925304
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Entity Type | Individual
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Provider Name | RYAN DREW BOGARD DDS
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Gender | Male
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Dates
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Enumeration Date | 04/28/2022
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Last Update Date | 04/28/2022
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Provider Practice Location Address
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Address Line | 310 TRI STATE PKWY STE 100
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City | GURNEE
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State | IL
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Zip | 60031-5282
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Country | US
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Telephone | 314-583-3104
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Fax |
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Provider Business Mailing Address
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Address Line | 1233 BLACKTHORN LN
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City | DEERFIELD
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State | IL
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Zip | 60015-3103
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Country | US
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Telephone | 314-583-3104
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 019.033452
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License Number State | IL
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