=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770624389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA ANNE BOGART D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 12/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 CENTRAL PARK S SUITE 2A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-371-5250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 CENTRAL PARK S SUITE 2A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-371-5250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 042936
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------