MEDICARE: GREGORY K. BOLLEN, DDS, P.A.

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	2890	AR

General Provider Information

NPI Number	:	1518379452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREGORY K. BOLLEN, DDS, P.A.

Provider Business Mailing Address
First Line	:	809 MARSHALL RD
Second Line	:
City	:	JACKSONVILLE
State	:	AR
Zip	:	72076-3744
Country	:	US
Telephone Number	:	501-982-4444
Fax Number	:	501-982-6616

Provider Business Practice Location Address
First Line	:	809 MARSHALL RD
Second Line	:
City	:	JACKSONVILLE
State	:	AR
Zip	:	72076-3744
Country	:	US
Telephone Number	:	501-982-4444
Fax Number	:	501-982-6616

Authorized Official
Title or Position	:	OFFICE MGR.
Name	:	MISS LISA ANN BROOKS
Credential	:	RDH
Telephone Number	:	501-982-4444

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	05/27/2014

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