Provider Demographics
NPI:1528072493
Name:MOGELOF DENTAL GROUP, LLC
Entity type:Organization
Organization Name:MOGELOF DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGELOF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-378-5588
Mailing Address - Street 1:2499 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5843
Mailing Address - Country:US
Mailing Address - Phone:203-378-5588
Mailing Address - Fax:
Practice Address - Street 1:2499 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5843
Practice Address - Country:US
Practice Address - Phone:203-378-5588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT49141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty