Provider Demographics
NPI:1063039352
Name:BOUZO, JESSICA (DMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOUZO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 W 74TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6512
Mailing Address - Country:US
Mailing Address - Phone:786-704-6559
Mailing Address - Fax:
Practice Address - Street 1:400 W 65TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6640
Practice Address - Country:US
Practice Address - Phone:305-827-0434
Practice Address - Fax:305-827-0501
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDM25090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty