Provider Demographics
NPI:1841365624
Name:BOLLA, COTTER & ASSOC., P.C.
Entity type:Organization
Organization Name:BOLLA, COTTER & ASSOC., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-982-9821
Mailing Address - Street 1:1125 THOMAS EDISON DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8500
Mailing Address - Country:US
Mailing Address - Phone:810-982-9821
Mailing Address - Fax:810-982-9645
Practice Address - Street 1:1125 THOMAS EDISON DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8500
Practice Address - Country:US
Practice Address - Phone:810-982-9821
Practice Address - Fax:810-982-9645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI123281223G0001X
MI0143921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty