Provider Demographics
NPI:1831165828
Name:BULKACZ, JAIME NMN (DDS PHD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:NMN
Last Name:BULKACZ
Suffix:
Gender:M
Credentials:DDS PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18740 VENTURA BLVD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:818-609-8655
Mailing Address - Fax:818-609-8644
Practice Address - Street 1:18740 VENTURA BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:818-609-8655
Practice Address - Fax:818-609-8644
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA322781223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics