Individual
MR. MARK R BOGNAR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
E 23970 POW WOW TRAIL RD, LAC VIEUX DESERT HEALTH CENTER, WATERSMEET, MI 49969-0249
(906) 358-4587
(906) 358-4118
Mailing address
PO BOX 249, WATERSMEET, MI 49969-0249
(906) 358-4587
(906) 358-4118
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
2901019957
MI
122300000X
Dentist
3856015
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33731100
—
WI
01
—
45575
SECURITY HEALTH PLAN
WI
Enumeration date
08/04/2006
Last updated
03/09/2009
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