Provider Demographics
NPI:1972052322
Name:BOLSA DENTAL CENTER
Entity Type:Organization
Organization Name:BOLSA DENTAL CENTER
Other - Org Name:RIVERWALK DENTAL SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRUC
Authorized Official - Middle Name:TRUNG
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-353-0050
Mailing Address - Street 1:11695 SLATE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-5197
Mailing Address - Country:US
Mailing Address - Phone:951-353-0050
Mailing Address - Fax:951-353-0060
Practice Address - Street 1:11695 SLATE AVE STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-5197
Practice Address - Country:US
Practice Address - Phone:951-353-0050
Practice Address - Fax:951-353-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA449341223G0001X
CA449331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty