Healthcare Provider Details

I. General information

NPI: 1962623819
Provider Name (Legal Business Name): J. SPENCER BOLEY D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 W WEDGE DR
FAYETTEVILLE AR
72704-7532
US

IV. Provider business mailing address

4501 W WEDGE DR
FAYETTEVILLE AR
72704-7532
US

V. Phone/Fax

Practice location:
  • Phone: 502-468-3170
  • Fax:
Mailing address:
  • Phone: 502-468-3170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3784
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: