Provider Demographics
NPI:1831291996
Name:BOLDT, MARK ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:BOLDT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2323 S. 109TH STREET
Mailing Address - Street 2:SUITE 295
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227
Mailing Address - Country:US
Mailing Address - Phone:414-545-5225
Mailing Address - Fax:414-545-5251
Practice Address - Street 1:2323 S. 109TH STREET
Practice Address - Street 2:SUITE 295
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227
Practice Address - Country:US
Practice Address - Phone:414-545-5225
Practice Address - Fax:414-545-5251
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4290-0151223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics