Provider Demographics
NPI:1679590004
Name:BOHOLST, ALBERT (DMD, PA)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:BOHOLST
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27510 CASHFORD CIR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6910
Mailing Address - Country:US
Mailing Address - Phone:813-973-8555
Mailing Address - Fax:
Practice Address - Street 1:27510 CASHFORD CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6910
Practice Address - Country:US
Practice Address - Phone:813-973-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL135361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6421540001Medicare NSC