Healthcare Provider Details

I. General information

NPI: 1720063225
Provider Name (Legal Business Name): WILLIAM G BOZALIS DDS MS PC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3613 NW 56TH SUITE 105 THREE CORPORATE PLAZA
OKLAHOMA CITY OK
73112
US

IV. Provider business mailing address

3613 NW 56TH SUITE 105 THREE CORPORATE PLAZA
OKLAHOMA CITY OK
73112
US

V. Phone/Fax

Practice location:
  • Phone: 405-946-2455
  • Fax: 405-946-3445
Mailing address:
  • Phone: 405-946-2455
  • Fax: 405-946-3445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3672
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: