Provider Demographics
NPI:1558584938
Name:MARK BOUKZAM DMD PA
Entity Type:Organization
Organization Name:MARK BOUKZAM DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOUKZAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-429-8506
Mailing Address - Street 1:4048 W HILLSBORO BLVD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442
Mailing Address - Country:US
Mailing Address - Phone:954-429-8506
Mailing Address - Fax:954-429-9480
Practice Address - Street 1:4048 W HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442
Practice Address - Country:US
Practice Address - Phone:954-429-8506
Practice Address - Fax:954-429-9480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty