Provider Demographics
NPI:1487664512
Name:BOJRAB, DAVID G (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:BOJRAB
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 1:4606 D EAST STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6963
Mailing Address - Country:US
Mailing Address - Phone:260-423-2340
Mailing Address - Fax:260-422-5342
Practice Address - Street 1:4606 D EAST STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815
Practice Address - Country:US
Practice Address - Phone:260-423-2340
Practice Address - Fax:260-422-5342
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1261791223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6185590001OtherNGS DME MAC
IN6185590001OtherDME MAC
IN200029030Medicaid
INT69229Medicare UPIN
IN203400Medicare PIN
IN200029030Medicaid
IN256430AMedicare PIN