Provider Demographics
NPI:1366658171
Name:BOLLA, DAVID R (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:BOLLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 THOMAS EDISON DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8500
Mailing Address - Country:US
Mailing Address - Phone:810-982-9821
Mailing Address - Fax:810-982-9645
Practice Address - Street 1:1125 THOMAS EDISON DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8500
Practice Address - Country:US
Practice Address - Phone:810-982-9821
Practice Address - Fax:810-982-9645
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0123281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice