Individual
DR. JIRIES PETER MOGANNAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S., M.D.
Contact information
Practice address
1111 SONOMA AVE, SUITE #220, SANTA ROSA, CA 95405-4819
(707) 566-7300
Mailing address
1111 SONOMA AVE, SUITE #220, SANTA ROSA, CA 95405-4819
(707) 566-7300
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
60191
CA
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
A114965
CA
Other
Enumeration date
11/05/2007
Last updated
08/17/2011
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