Provider Demographics
NPI:1386991446
Name:BOLIVAR, MARISOL (DMD, MS)
Entity type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:BOLIVAR
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:MARISOL
Other - Middle Name:
Other - Last Name:CARBONELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 PASEO REYES DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8462
Mailing Address - Country:US
Mailing Address - Phone:904-429-3387
Mailing Address - Fax:904-429-3888
Practice Address - Street 1:250 PASEO REYES DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8462
Practice Address - Country:US
Practice Address - Phone:904-429-3387
Practice Address - Fax:904-429-3888
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN229441223P0221X
VA04014137441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty