MEDICARE: DR. ROBERT CLIFFORD BOUGGY D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12008204B	IN

General Provider Information

NPI Number	:	1710010863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT CLIFFORD BOUGGY D.D.S.

Provider Business Mailing Address
First Line	:	1827 NORTHWESTERN AVE
Second Line	:
City	:	WEST LAFAYETTE BRA
State	:	IN
Zip	:	47906-2279
Country	:	US
Telephone Number	:	765-463-5561
Fax Number	:

Provider Business Practice Location Address
First Line	:	1827 NORTHWESTERN AVE
Second Line	:
City	:	WEST LAFAYETTE BRA
State	:	IN
Zip	:	47906-2279
Country	:	US
Telephone Number	:	765-463-5561
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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