Provider Demographics
NPI:1023171774
Name:BOLZ, JEFFREY N (DDS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:N
Last Name:BOLZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 NE 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2610
Mailing Address - Country:US
Mailing Address - Phone:218-326-3240
Mailing Address - Fax:218-326-3343
Practice Address - Street 1:512 NE 1ST AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2610
Practice Address - Country:US
Practice Address - Phone:218-326-3240
Practice Address - Fax:218-326-3343
Is Sole Proprietor?:No
Enumeration Date:2006-12-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9203122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist