Healthcare Provider Details

I. General information

NPI: 1386991446
Provider Name (Legal Business Name): MARISOL BOLIVAR DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARISOL CARBONELL

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PASEO REYES DR
ST AUGUSTINE FL
32095-8462
US

IV. Provider business mailing address

250 PASEO REYES DR
ST AUGUSTINE FL
32095-8462
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-3387
  • Fax: 904-429-3888
Mailing address:
  • Phone: 904-429-3387
  • Fax: 904-429-3888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN22944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: