Provider Demographics
NPI:1144409947
Name:IVANOV, BOGDAN KONSTANTINOV (DMD)
Entity Type:Individual
Prefix:DR
First Name:BOGDAN
Middle Name:KONSTANTINOV
Last Name:IVANOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 E KENNEDY BLVD
Mailing Address - Street 2:SCC DENTAL CLINIC - HCHD
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3511
Mailing Address - Country:US
Mailing Address - Phone:352-397-6186
Mailing Address - Fax:813-273-3721
Practice Address - Street 1:1105 E KENNEDY BLVD
Practice Address - Street 2:SCC DENTAL CLINIC - HCHD
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-3511
Practice Address - Country:US
Practice Address - Phone:352-397-6186
Practice Address - Fax:813-273-3721
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist