Provider Demographics
NPI:1033263629
Name:BOLGREN, DANIEL L (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:BOLGREN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:L
Other - Last Name:BOLGREN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, PC
Mailing Address - Street 1:1920 JOHN F KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-3896
Mailing Address - Country:US
Mailing Address - Phone:563-557-8150
Mailing Address - Fax:
Practice Address - Street 1:1920 JOHN F KENNEDY RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-3896
Practice Address - Country:US
Practice Address - Phone:563-557-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA62591223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics