Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 012009 | MO |
NPI | 1104010255 |
---|---|
Provider Name | Michael Bruce Hogan |
First Address | Camdenton, MO 65020-7066 |
Second Address | Camdenton, MO 65020-7066 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2007 |
Last Update Date | 31/08/2007 |