Provider Demographics
NPI:1285779827
Name:BOHRER, BLAINE TRAVIS (DDS)
Entity type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:TRAVIS
Last Name:BOHRER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 LEVEL LOOP RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-6716
Mailing Address - Country:US
Mailing Address - Phone:757-689-8809
Mailing Address - Fax:
Practice Address - Street 1:1577 GENERAL BOOTH BLVD
Practice Address - Street 2:107
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5105
Practice Address - Country:US
Practice Address - Phone:757-428-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014107221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice