Provider Demographics
NPI:1295850154
Name:BOLYSHKANOV, VERA (DDS)
Entity Type:Individual
Prefix:
First Name:VERA
Middle Name:
Last Name:BOLYSHKANOV
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 1:6137 WATT AVE
Mailing Address - Street 2:STE 8
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660
Mailing Address - Country:US
Mailing Address - Phone:916-331-7000
Mailing Address - Fax:916-331-7007
Practice Address - Street 1:6137 WATT AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:NORTH HIGHLANDS
Practice Address - State:CA
Practice Address - Zip Code:95660
Practice Address - Country:US
Practice Address - Phone:916-331-7000
Practice Address - Fax:916-331-7007
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA482331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice