Provider Demographics
NPI:1063039352
Name:BOUZO, JESSICA (DMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOUZO
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 1:2480 W 74TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6512
Mailing Address - Country:US
Mailing Address - Phone:786-704-6559
Mailing Address - Fax:
Practice Address - Street 1:6500 COW PEN RD STE 104
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-7620
Practice Address - Country:US
Practice Address - Phone:305-827-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDM25090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty