Provider Demographics
NPI:1679622484
Name:BOHACEK, LINDA KAY (RDH, MA, CDHC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:KAY
Last Name:BOHACEK
Suffix:
Gender:F
Credentials:RDH, MA, CDHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-5912
Mailing Address - Country:US
Mailing Address - Phone:715-579-5009
Mailing Address - Fax:715-835-8918
Practice Address - Street 1:720 2ND AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-5413
Practice Address - Country:US
Practice Address - Phone:715-839-4718
Practice Address - Fax:715-839-1674
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4279-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33805400Medicaid