Healthcare Provider Details

I. General information

NPI: 1336202951
Provider Name (Legal Business Name): DR. BOLIVAR LUPERON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BOLIVAR LUPERON NOVA DMD

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W COURT SQ STE 325
DECATUR GA
30030-2576
US

IV. Provider business mailing address

1 W COURT SQ STE 325
DECATUR GA
30030-2576
US

V. Phone/Fax

Practice location:
  • Phone: 470-568-2781
  • Fax:
Mailing address:
  • Phone: 470-568-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013214
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN013214
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: