Provider Demographics
NPI:1750653499
Name:BOEKWEG, EZRA
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:
Last Name:BOEKWEG
Suffix:
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 1:121 EASTGATE PLZ
Mailing Address - Street 2:
Mailing Address - City:BELLMEAD
Mailing Address - State:TX
Mailing Address - Zip Code:76705-2868
Mailing Address - Country:US
Mailing Address - Phone:254-799-4867
Mailing Address - Fax:
Practice Address - Street 1:121 EASTGATE PLZ
Practice Address - Street 2:
Practice Address - City:BELLMEAD
Practice Address - State:TX
Practice Address - Zip Code:76705-2868
Practice Address - Country:US
Practice Address - Phone:254-799-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27552122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist