Provider Demographics
NPI:1215157631
Name:BOLMGREN, GARY ALAN (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALAN
Last Name:BOLMGREN
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Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:381 SOUTHDALE MEDICAL CENTER
Mailing Address - Street 2:6545 FRANCE AVE. S.
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2121
Mailing Address - Country:US
Mailing Address - Phone:952-926-7766
Mailing Address - Fax:952-926-2037
Practice Address - Street 1:381 SOUTHDALE MEDICAL CENTER
Practice Address - Street 2:6545 FRANCE AVE. S.
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2121
Practice Address - Country:US
Practice Address - Phone:952-926-7766
Practice Address - Fax:952-926-2037
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN91291223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics