Provider Demographics
NPI:1396926150
Name:BOLANOS, ALBERTO EDINSON (DDS)
Entity type:Individual
Prefix:
First Name:ALBERTO
Middle Name:EDINSON
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-4011
Mailing Address - Country:US
Mailing Address - Phone:239-304-1974
Mailing Address - Fax:239-304-1971
Practice Address - Street 1:4060 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-4011
Practice Address - Country:US
Practice Address - Phone:239-304-1974
Practice Address - Fax:239-304-1974
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053453-11223G0001X
FL180411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02908818Medicaid