Provider Demographics
NPI:1982220562
Name:BOELMAN, GUNNAR ANTON (DMD)
Entity Type:Individual
Prefix:
First Name:GUNNAR
Middle Name:ANTON
Last Name:BOELMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 SADIE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6683
Mailing Address - Country:US
Mailing Address - Phone:909-548-9979
Mailing Address - Fax:
Practice Address - Street 1:3400 TEXAS SAGE TRL STE 136
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8604
Practice Address - Country:US
Practice Address - Phone:817-750-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX362161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice