Provider Demographics
NPI:1063547008
Name:BOLTHOUSE, JOHN P (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:BOLTHOUSE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3100 IVANREST AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2930
Mailing Address - Country:US
Mailing Address - Phone:616-538-1260
Mailing Address - Fax:616-538-5540
Practice Address - Street 1:3100 IVANREST AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2930
Practice Address - Country:US
Practice Address - Phone:616-538-1260
Practice Address - Fax:616-538-5540
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI085541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics