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General NPI Number Information
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NPI Number | 1447591789
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Entity Type | Individual
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Provider Name | AMY JOHANNA BOUVIER POBLENZ D.M.D., M.S.
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Gender | Female
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 02/06/2018
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Provider Practice Location Address
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Address Line | 1023 ATLANTIC BLVD
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City | ATLANTIC BEACH
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State | FL
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Zip | 32233-3313
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Country | US
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Telephone | 904-249-3104
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Fax | 904-249-3109
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Provider Business Mailing Address
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Address Line | 1023 ATLANTIC BLVD
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City | ATLANTIC BEACH
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State | FL
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Zip | 32233-3313
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Country | US
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Telephone | 904-249-3104
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Fax | 904-249-3109
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 62078
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 9611
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN18750
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License Number State | FL
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