Basic Information
| Provider Information | |||||||||
| NPI: | 1174524995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLAK | ||||||||
| FirstName: | COOPER | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4722 FAUNTLEROY WAY SW STE A | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981164667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069286242 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4722 FAUNTLEROY WAY SW STE A | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981164667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069286242 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 8407 | CO | N | Dental Providers | Dentist | General Practice | 1223G0001X | 25944 | TX | N | Dental Providers | Dentist | General Practice | 1223G0001X | DE60350473 | WA | Y | Dental Providers | Dentist | General Practice |
No ID Information.