Provider Demographics
NPI:1407907223
Name:BOLTIE, KARL OMER (DDS)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:OMER
Last Name:BOLTIE
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 1:4708 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2930
Mailing Address - Country:US
Mailing Address - Phone:956-972-1558
Mailing Address - Fax:956-972-1558
Practice Address - Street 1:1211 RAUL LONGORIA RD.
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589
Practice Address - Country:US
Practice Address - Phone:956-787-4840
Practice Address - Fax:956-787-4840
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist