Provider Demographics
NPI:1629362363
Name:BOZANICH, JOHN MICHAEL (DDS, MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:BOZANICH
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 SHERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4660
Mailing Address - Country:US
Mailing Address - Phone:281-731-9403
Mailing Address - Fax:
Practice Address - Street 1:2305 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3157
Practice Address - Country:US
Practice Address - Phone:707-525-1500
Practice Address - Fax:707-525-0315
Is Sole Proprietor?:No
Enumeration Date:2011-05-29
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX264981223P0300X
CA1037831223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics