Provider Demographics
NPI:1649457565
Name:BOLDT, DANA MICHELLE (LAC)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:MICHELLE
Last Name:BOLDT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2107
Mailing Address - Country:US
Mailing Address - Phone:213-400-7700
Mailing Address - Fax:
Practice Address - Street 1:12114 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3812
Practice Address - Country:US
Practice Address - Phone:310-397-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11902171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist