Provider Demographics
NPI:1558422725
Name:BOHANNAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:BOHANNAN DENTAL CORPORATION
Other - Org Name:WILLIAM B. BOHANNAN DDS, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOHANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:408-286-1553
Mailing Address - Street 1:2025 FOREST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4806
Mailing Address - Country:US
Mailing Address - Phone:408-286-1553
Mailing Address - Fax:408-286-8511
Practice Address - Street 1:2025 FOREST AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4806
Practice Address - Country:US
Practice Address - Phone:408-286-1553
Practice Address - Fax:408-286-8511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66471261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery