Provider Demographics
NPI:1669510038
Name:BOZA, GERALD M JR
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:M
Last Name:BOZA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9902 LONE TREE LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-4431
Mailing Address - Country:US
Mailing Address - Phone:813-963-2276
Mailing Address - Fax:813-935-6953
Practice Address - Street 1:2600 W SLIGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-4342
Practice Address - Country:US
Practice Address - Phone:813-932-9178
Practice Address - Fax:813-935-6953
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL56381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice