Provider Demographics
NPI:1598899593
Name:BUKZIN, MITCHELL JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:JAY
Last Name:BUKZIN
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 1:4391 RIDGEWOOD CENTER DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5399
Mailing Address - Country:US
Mailing Address - Phone:703-590-4666
Mailing Address - Fax:703-897-1526
Practice Address - Street 1:4391 RIDGEWOOD CENTER DR
Practice Address - Street 2:SUITE C
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5399
Practice Address - Country:US
Practice Address - Phone:703-590-4666
Practice Address - Fax:703-897-1526
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010038171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice