Provider Demographics
NPI:1386720472
Name:COGLEY, VAN SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:VAN
Middle Name:SCOTT
Last Name:COGLEY
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 1:3 VINE AVE NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5069
Mailing Address - Country:US
Mailing Address - Phone:850-243-2312
Mailing Address - Fax:850-243-7013
Practice Address - Street 1:3 VINE AVE NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5069
Practice Address - Country:US
Practice Address - Phone:850-243-2312
Practice Address - Fax:850-243-7013
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN104661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice