Provider Demographics
NPI:1710092432
Name:BOGUCKI, GERARD EDWARD-ZACKARY (DMD)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:EDWARD-ZACKARY
Last Name:BOGUCKI
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 1:66 MAPLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06019
Mailing Address - Country:US
Mailing Address - Phone:860-693-8314
Mailing Address - Fax:860-693-4426
Practice Address - Street 1:66 MAPLE AVENUE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06019
Practice Address - Country:US
Practice Address - Phone:860-693-8314
Practice Address - Fax:860-693-4426
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT50721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice