Provider Demographics
NPI:1811069198
Name:BOLT, DANIEL L (DDS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:BOLT
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 1:845 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423
Mailing Address - Country:US
Mailing Address - Phone:616-392-2381
Mailing Address - Fax:
Practice Address - Street 1:845 E. 16TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-392-2381
Practice Address - Fax:616-392-3748
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010176021223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124383607Medicaid