Provider Demographics
NPI:1538601117
Name:SUSAN A BOLLINGER DDS
Entity type:Organization
Organization Name:SUSAN A BOLLINGER DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KENNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-759-7007
Mailing Address - Street 1:1401 AVOCADO AVE STE 309
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8733
Mailing Address - Country:US
Mailing Address - Phone:949-759-7007
Mailing Address - Fax:
Practice Address - Street 1:1401 AVOCADO AVE STE 309
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8733
Practice Address - Country:US
Practice Address - Phone:949-759-7007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26589332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7560010001OtherPTAN