Provider Demographics
NPI:1740322767
Name:BOLAND, JOHN EDWIN IV (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWIN
Last Name:BOLAND
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:770 TAMALPAIS DR STE 404
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1739
Mailing Address - Country:US
Mailing Address - Phone:415-927-9052
Mailing Address - Fax:415-927-2231
Practice Address - Street 1:770 TAMALPAIS DR STE 404
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1739
Practice Address - Country:US
Practice Address - Phone:415-927-9052
Practice Address - Fax:415-927-2231
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist