Provider Demographics
NPI:1144347360
Name:MACDONALD, BO L (DDS)
Entity type:Individual
Prefix:DR
First Name:BO
Middle Name:L
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11340 W. OLYMPIC BLVD.
Mailing Address - Street 2:148
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:310-479-4459
Mailing Address - Fax:310-477-9239
Practice Address - Street 1:11340 W OLYMPIC BLVD
Practice Address - Street 2:148
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1608
Practice Address - Country:US
Practice Address - Phone:310-479-4459
Practice Address - Fax:310-477-9239
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0369591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice