Provider Demographics
NPI:1043545346
Name:WOGMAN, LARRY S (DDS)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:S
Last Name:WOGMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 JAY ST.
Mailing Address - Street 2:
Mailing Address - City:FOSSIL
Mailing Address - State:OR
Mailing Address - Zip Code:97830-0307
Mailing Address - Country:US
Mailing Address - Phone:541-763-2725
Mailing Address - Fax:
Practice Address - Street 1:340 SE HIGH ST.
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:OR
Practice Address - Zip Code:97750-0304
Practice Address - Country:US
Practice Address - Phone:541-462-3313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9235122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist