Provider Demographics
NPI:1306073754
Name:AMOLI, BOUALI FREDERICK (DMD MD)
Entity type:Individual
Prefix:DR
First Name:BOUALI
Middle Name:FREDERICK
Last Name:AMOLI
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5149 NORMANDY BLVD UNIT 4
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-4861
Mailing Address - Country:US
Mailing Address - Phone:904-781-1201
Mailing Address - Fax:
Practice Address - Street 1:5149 NORMANDY BLVD UNIT 4
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4861
Practice Address - Country:US
Practice Address - Phone:904-781-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRP7811223S0112X
FLME119684204E00000X
FLDN 210291223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012224600Medicaid