Provider Demographics
NPI:1295404986
Name:BULZA, MARLO (DMD)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:BULZA
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 1:836 S CURRY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4753
Mailing Address - Country:US
Mailing Address - Phone:971-404-5422
Mailing Address - Fax:
Practice Address - Street 1:16679 BOONES FERRY RD STE 215
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4368
Practice Address - Country:US
Practice Address - Phone:503-636-7601
Practice Address - Fax:503-636-3749
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD115281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice