Provider Demographics
NPI:1447591789
Name:BOUVIER POBLENZ, AMY JOHANNA (DMD, MS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOHANNA
Last Name:BOUVIER POBLENZ
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3313
Mailing Address - Country:US
Mailing Address - Phone:904-249-3104
Mailing Address - Fax:904-249-3109
Practice Address - Street 1:1023 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-3313
Practice Address - Country:US
Practice Address - Phone:904-249-3104
Practice Address - Fax:904-249-3109
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62078122300000X
TN96111223X0400X
FLDN187501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist