Provider Demographics
NPI:1508101338
Name:BUKOVAC, CHARLES (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BUKOVAC
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 1:1687 DOVE RD
Mailing Address - Street 2:
Mailing Address - City:SORENTO
Mailing Address - State:IL
Mailing Address - Zip Code:62086-3254
Mailing Address - Country:US
Mailing Address - Phone:618-604-2111
Mailing Address - Fax:
Practice Address - Street 1:215 SOUTH STURGEON ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361
Practice Address - Country:US
Practice Address - Phone:573-564-3726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120295421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice