Healthcare Provider Details

I. General information

NPI: 1285689570
Provider Name (Legal Business Name): RICHARD JOHN BOBULSKY DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7057 W 130TH ST SUITE 203
PARMA HEIGHTS OH
44130-7841
US

IV. Provider business mailing address

7057 W 130TH ST SUITE 203
PARMA HEIGHTS OH
44130-7841
US

V. Phone/Fax

Practice location:
  • Phone: 440-885-4200
  • Fax: 440-885-0082
Mailing address:
  • Phone: 440-885-4200
  • Fax: 440-885-0082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number17306
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: