Provider Demographics
NPI:1043530462
Name:MUNGUBA, BOZENA ZALESKA (DMD)
Entity Type:Individual
Prefix:DR
First Name:BOZENA
Middle Name:ZALESKA
Last Name:MUNGUBA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:352-360-2389
Practice Address - Street 1:225 N 1ST ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5150
Practice Address - Country:US
Practice Address - Phone:352-314-7400
Practice Address - Fax:352-360-2389
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN190161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010593000Medicaid