Provider Demographics
NPI:1164571402
Name:BOLANIS, ANNA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:M
Last Name:BOLANIS
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 1:760 WEST LAKESHORE DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-1580
Mailing Address - Country:US
Mailing Address - Phone:802-862-9282
Mailing Address - Fax:
Practice Address - Street 1:760 WEST LAKESHORE DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-1580
Practice Address - Country:US
Practice Address - Phone:802-862-9282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT11511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1003605Medicaid