Provider Demographics
NPI:1972260800
Name:ADVANCED SMILES MARION, KYLE D BOGAN, DDS, LLC
Entity type:Organization
Organization Name:ADVANCED SMILES MARION, KYLE D BOGAN, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-725-8080
Mailing Address - Street 1:7325 GOODING BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-7086
Mailing Address - Country:US
Mailing Address - Phone:740-725-8080
Mailing Address - Fax:740-548-1804
Practice Address - Street 1:1269 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6419
Practice Address - Country:US
Practice Address - Phone:740-725-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-28
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty