Provider Demographics
NPI:1174598916
Name:KOGAN, PAUL (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:KOGAN
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 1:702 E BELL RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-6639
Mailing Address - Country:US
Mailing Address - Phone:602-482-7000
Mailing Address - Fax:602-482-7021
Practice Address - Street 1:702 E BELL RD
Practice Address - Street 2:SUITE 111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-6639
Practice Address - Country:US
Practice Address - Phone:602-404-3800
Practice Address - Fax:602-404-8757
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD65241223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ961046Medicaid