Provider Demographics
NPI:1174524995
Name:BOLAK, COOPER FRANCIS (DDS)
Entity type:Individual
Prefix:DR
First Name:COOPER
Middle Name:FRANCIS
Last Name:BOLAK
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 1:4722 FAUNTLEROY WAY SW STE A
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4667
Mailing Address - Country:US
Mailing Address - Phone:206-928-6242
Mailing Address - Fax:
Practice Address - Street 1:4722 FAUNTLEROY WAY SW STE A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4667
Practice Address - Country:US
Practice Address - Phone:206-928-6242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO84071223G0001X
TX259441223G0001X
WADE603504731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice