Provider Demographics
NPI:1679531867
Name:BOLAND, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:BOLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6540 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-6822
Mailing Address - Country:US
Mailing Address - Phone:727-525-0155
Mailing Address - Fax:727-520-7173
Practice Address - Street 1:6540 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-6822
Practice Address - Country:US
Practice Address - Phone:727-525-0155
Practice Address - Fax:727-520-7173
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00506331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046922000Medicaid
FLD20937Medicare UPIN
FL046922000Medicaid