Provider Demographics
NPI:1528081742
Name:BOGACKI, MICHELE T (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:T
Last Name:BOGACKI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4452 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3302
Mailing Address - Country:US
Mailing Address - Phone:773-777-4800
Mailing Address - Fax:773-777-4918
Practice Address - Street 1:4452 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3302
Practice Address - Country:US
Practice Address - Phone:773-777-4800
Practice Address - Fax:773-777-4918
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice