Provider Demographics
NPI:1831676386
Name:BOUZ, SVIATOSLAV (DDS)
Entity Type:Individual
Prefix:DR
First Name:SVIATOSLAV
Middle Name:
Last Name:BOUZ
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 1:1205 CLIFF WHITE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-8034
Mailing Address - Country:US
Mailing Address - Phone:909-855-6942
Mailing Address - Fax:
Practice Address - Street 1:704 HIGHWAY 100 STE 101
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033
Practice Address - Country:US
Practice Address - Phone:931-729-2664
Practice Address - Fax:931-729-2666
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10755122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist