Provider Demographics
NPI:1457554602
Name:BOLLAERT, BRIAN JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:BOLLAERT
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 1:2909 19TH STREET
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244
Mailing Address - Country:US
Mailing Address - Phone:309-796-2251
Mailing Address - Fax:309-796-2274
Practice Address - Street 1:2909 19TH STREET
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244
Practice Address - Country:US
Practice Address - Phone:309-796-2251
Practice Address - Fax:309-796-2274
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice