Healthcare Provider Details

I. General information

NPI: 1487664512
Provider Name (Legal Business Name): DAVID G BOJRAB DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 D EAST STATE BLVD
FORT WAYNE IN
46815
US

IV. Provider business mailing address

4606 D EAST STATE BLVD
FORT WAYNE IN
46815-6963
US

V. Phone/Fax

Practice location:
  • Phone: 260-423-2340
  • Fax: 260-422-5342
Mailing address:
  • Phone: 260-423-2340
  • Fax: 260-422-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number126179
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: