Provider Demographics
NPI:1225920853
Name:BOULEVARD DENTAL CITRUS PARK, LLC
Entity type:Organization
Organization Name:BOULEVARD DENTAL CITRUS PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WUJICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-262-5220
Mailing Address - Street 1:8325 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1608
Mailing Address - Country:US
Mailing Address - Phone:813-792-0041
Mailing Address - Fax:
Practice Address - Street 1:8325 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1608
Practice Address - Country:US
Practice Address - Phone:813-792-0041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-17
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty