Provider Demographics
NPI:1285122044
Name:KENNETH A MOGELL DMD PA
Entity type:Organization
Organization Name:KENNETH A MOGELL DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TREAS
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-271-2483
Mailing Address - Street 1:2900 N MILITARY TRL STE 212
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 PINE ST STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3170
Practice Address - Country:US
Practice Address - Phone:321-313-5350
Practice Address - Fax:561-988-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty