Healthcare Provider Details

I. General information

NPI: 1598899593
Provider Name (Legal Business Name): MITCHELL JAY BUKZIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4391 RIDGEWOOD CENTER DR SUITE C
WOODBRIDGE VA
22192-5399
US

IV. Provider business mailing address

4391 RIDGEWOOD CENTER DR SUITE C
WOODBRIDGE VA
22192-5399
US

V. Phone/Fax

Practice location:
  • Phone: 703-590-4666
  • Fax: 703-897-1526
Mailing address:
  • Phone: 703-590-4666
  • Fax: 703-897-1526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401003817
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: