Healthcare Provider Details

I. General information

NPI: 1740364066
Provider Name (Legal Business Name): JAY MEYER BUKZIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7915 LAKE MANASSAS DRIVE SUITE 115
GAINESVILLE VA
20155
US

IV. Provider business mailing address

7915 LAKE MANASSAS DRIVE SUITE 115
GAINESVILLE VA
20155
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-7933
  • Fax: 703-743-9089
Mailing address:
  • Phone: 703-753-7933
  • Fax: 703-743-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberG10001119
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02247000
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401411256
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS035695
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8416
License Number StateKY
# 6
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0438000212
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: