Healthcare Provider Details

I. General information

NPI: 1336271170
Provider Name (Legal Business Name): PAUL GUNNAR BOHMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 S VICTORIA AVE SUITE 250
VENTURA CA
93003
US

IV. Provider business mailing address

1280 S VICTORIA AVE SUITE 250
VENTURA CA
93003-6555
US

V. Phone/Fax

Practice location:
  • Phone: 805-642-8672
  • Fax: 805-642-8686
Mailing address:
  • Phone: 805-642-8672
  • Fax: 805-642-8686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDDS43902
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS2-156C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: