Provider Demographics
NPI:1376844209
Name:BOZAVIKOV, PETER (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BOZAVIKOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12307-1508
Mailing Address - Country:US
Mailing Address - Phone:518-370-1441
Mailing Address - Fax:518-395-9431
Practice Address - Street 1:1044 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12307-1508
Practice Address - Country:US
Practice Address - Phone:518-370-1441
Practice Address - Fax:518-395-9431
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02995513Medicaid
NY02995513Medicaid
NY53099AMedicare PIN