Healthcare Provider Details

I. General information

NPI: 1992717284
Provider Name (Legal Business Name): JOHN EDWIN BOLAND III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 TAMALPAIS DR SUITE 404
CORTE MADERA CA
94925-1700
US

IV. Provider business mailing address

770 TAMALPAIS DR SUITE 404
CORTE MADERA CA
94925-1700
US

V. Phone/Fax

Practice location:
  • Phone: 415-927-7711
  • Fax:
Mailing address:
  • Phone: 415-927-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: