MEDICARE: DR. BROCK KEITH BOHLMAN D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D1972	ID

General Provider Information

NPI Number	:	1891878484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROCK KEITH BOHLMAN D.D.S

Provider Business Mailing Address
First Line	:	594 WEST GRAYFOX CT.
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646
Country	:	US
Telephone Number	:	208-895-8563
Fax Number	:

Provider Business Practice Location Address
First Line	:	5993 W STATE ST STE B
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83703-3039
Country	:	US
Telephone Number	:	208-384-0577
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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