MEDICARE: DR. WINNIE C BOLING DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7996	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34-1978044	OTHER	KY	TAX ID

General Provider Information

NPI Number	:	1326070061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WINNIE C BOLING DMD

Provider Business Mailing Address
First Line	:	214 PARKER DR
Second Line	:
City	:	LAGRANGE
State	:	KY
Zip	:	40031-1200
Country	:	US
Telephone Number	:	502-222-2216
Fax Number	:	502-222-2116

Provider Business Practice Location Address
First Line	:	214 PARKER DR
Second Line	:
City	:	LAGRANGE
State	:	KY
Zip	:	40031-1200
Country	:	US
Telephone Number	:	502-222-2216
Fax Number	:	502-222-2116

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	09/04/2008

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