Healthcare Provider Details

I. General information

NPI: 1326070061
Provider Name (Legal Business Name): WINNIE C BOLING DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 PARKER DR
LAGRANGE KY
40031-1200
US

IV. Provider business mailing address

214 PARKER DR
LAGRANGE KY
40031-1200
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-2216
  • Fax: 502-222-2116
Mailing address:
  • Phone: 502-222-2216
  • Fax: 502-222-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7996
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: