Healthcare Provider Details

I. General information

NPI: 1669533832
Provider Name (Legal Business Name): WILLIAM B. BOHANNAN DDS, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 EL CAMINO REAL SUITE 403
BURLINGAME CA
94010-3228
US

IV. Provider business mailing address

1750 EL CAMINO REAL SUITE 403
BURLINGAME CA
94010-3228
US

V. Phone/Fax

Practice location:
  • Phone: 650-692-1530
  • Fax: 650-692-2655
Mailing address:
  • Phone: 650-692-1530
  • Fax: 650-692-2655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberA64471
License Number StateCA

VIII. Authorized Official

Name: DR. WILLIAM B BOHANNAN
Title or Position: PRESIDENT OWNER
Credential: D.D.S., M.D.
Phone: 650-692-1530