Provider Demographics
NPI:1770893927
Name:ALBERT BOHOLST DMD, PA
Entity type:Organization
Organization Name:ALBERT BOHOLST DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOHOLST
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-973-8555
Mailing Address - Street 1:27510 CASHFORD CIR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6910
Mailing Address - Country:US
Mailing Address - Phone:813-973-8555
Mailing Address - Fax:813-354-2573
Practice Address - Street 1:27510 CASHFORD CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6910
Practice Address - Country:US
Practice Address - Phone:813-973-8555
Practice Address - Fax:813-354-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13536332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6421540001Medicare NSC