Provider Demographics
NPI:1841084209
Name:BOLLE-VAN LOO, LEAH
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:BOLLE-VAN LOO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 WAITE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1229
Mailing Address - Country:US
Mailing Address - Phone:541-756-6232
Mailing Address - Fax:541-756-6234
Practice Address - Street 1:1885 WAITE ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1210
Practice Address - Country:US
Practice Address - Phone:541-696-5006
Practice Address - Fax:541-756-6234
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR002377126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant