Provider Demographics
NPI:1598704033
Name:BOHNA, THOMAS ALBERT (LD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALBERT
Last Name:BOHNA
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 NE 154TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-7418
Mailing Address - Country:US
Mailing Address - Phone:360-260-0122
Mailing Address - Fax:
Practice Address - Street 1:14602 NE 4TH PLAIN RD
Practice Address - Street 2:SUITE G
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-5000
Practice Address - Country:US
Practice Address - Phone:360-882-4884
Practice Address - Fax:360-882-7588
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN0130122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5025259Medicaid