Healthcare Provider Details

I. General information

NPI: 1770348393
Provider Name (Legal Business Name): LILY BOZAGLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

976 BARD AVE
STATEN ISLAND NY
10301-3322
US

IV. Provider business mailing address

2601 OCEAN PKWY
BROOKLYN NY
11235-7745
US

V. Phone/Fax

Practice location:
  • Phone: 718-448-1866
  • Fax:
Mailing address:
  • Phone: 718-616-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number064909
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: