Provider Demographics
NPI:1417394198
Name:KONZELA, MICHAEL J (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:KONZELA
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 1:1501 CORPORATE DR
Mailing Address - Street 2:SUITE140
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-6600
Mailing Address - Country:US
Mailing Address - Phone:561-364-8700
Mailing Address - Fax:561-364-1816
Practice Address - Street 1:1501 CORPORATE DR
Practice Address - Street 2:SUITE140
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6600
Practice Address - Country:US
Practice Address - Phone:561-364-8700
Practice Address - Fax:561-364-1816
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN112961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice