Provider Demographics
NPI:1285794560
Name:MOGREN, NATHAN WILLIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:WILLIAM
Last Name:MOGREN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7640 FOREST WAY
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8492
Mailing Address - Country:US
Mailing Address - Phone:815-389-9597
Mailing Address - Fax:
Practice Address - Street 1:7912 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-2812
Practice Address - Country:US
Practice Address - Phone:815-633-4715
Practice Address - Fax:815-633-7775
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice