Basic Information
| Provider Information | |||||||||
| NPI: | 1043530462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNGUBA | ||||||||
| FirstName: | BOZENA | ||||||||
| MiddleName: | ZALESKA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 3523602389 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347485150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523147400 | ||||||||
| FaxNumber: | 3523602389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2010 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN19016 | FL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 010593000 | 05 | FL | MEDICAID |