Provider Demographics
NPI:1861536146
Name:BOLANOS, CAROL (DMD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:BOLANOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 NEWTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-3059
Mailing Address - Country:US
Mailing Address - Phone:856-889-8777
Mailing Address - Fax:
Practice Address - Street 1:3223 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02098300122300000X
PADS043950122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist